Tip 246: cooling for HIE

A systematic review of several large multi-centre RCTs for therapeutic cooling to treat hypoxic-ischaemic encephalopathy included:

  • Cool Cap (2005, 234 infants, head cooling only);
  • NICHD (2005, 208 infants);
  • TOBY (2009, 325 infants).

It showed a statistically significant reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age (RR 0.75; 95% CI 0.68 to 0.83), and in each of these outcomes alone (i.e. cooling reduces mortality without increasing major disability in survivors).

Adverse effects include sinus bradycardia and thrombocytopenia.

Reference: Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD003311. DOI: 10.1002/14651858.CD003311.pub3.

Previously published: 16/06/15

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Tip 245: the TOBY study

The TOBY (TOtal BodY hypothermia for perinatal asphyxial encephalopathy) study used moderate hypothermia (33.5°C for 72 hours) in neonates ≥36/40 with the primary outcome of death or severe disability at 18 months of age.

The study did not prove a reduction in either death, severe disability or these combined (RR of death or severe disability 0.86; 95% CI 0.68 to 1.07; P=0.17).

However, it did show improved survival without neurological abnormality (RR 1.57; 95% CI 1.16 to 2.12; P=0.003).

Reference: Azzopardi, D. V., Strohm, B., Edwards, A. D., Dyet, L., Halliday, H. L., Juszczak, E., … & Brocklehurst, P. (2009). Moderate hypothermia to treat perinatal asphyxial encephalopathy. New England Journal of Medicine; 361(14): 1349-1358 (325 babies).

Previously published: 09/06/15

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Tip 244: epiphora

Epiphora is a watering eye, which is infants is usually caused by delayed canalisation of the nasolacrimal duct mucosa. It can be present in up to 20% of infants.

Most cases resolve spontaneously by 18 months of age without any complications from infection. Massage over the tear sac may shorten the time to resolution.

Reference: Takahashi, Y., Kakizaki, H., Chan, W. O., & Selva, D. (2010). Management of congenital nasolacrimal duct obstruction. Acta ophthalmologica, 88(5), 506-513.

Previously published: 01/06/15

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Tip 243: neonatal hypoglycaemia 3

The definition of neonatal hypoglycaemia is capillary plasma glucose <2.6 mmol/L.

The threshold for invasive treatment (nasogastric feeds or IV Dextrose) is glucose <2.0 mmol/L on two consecutive readings despite maximal support for feeding, or if the baby is not feeding effectively.

Any baby with clinical signs of hypoglycaemia, should be admitted to the neonatal unit and treated with IV Dextrose as soon as possible.

Reference: National Institute for Health and Clinical Excellence (2015). Diabetes in pregnancy: Management of diabetes and its complications from preconception to the postnatal period. Version 2.1. Nice Guideline (NG) 3. London: NICE.

Previously published: 25/05/15

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Tip 242: acute liver failure 3

About 60% of deaths in acute liver failure have been attributed to sepsis.

The most common organism is Staphylococcus aureus.

Other organisms are: Streptococci, coliforms and Candida species.

Reference: Dhawan, A., & Mieli-Vergani, G. (2005). Acute liver failure in neonates. Early Human Development; 81: 1005—1010.

Previously published: 11/05/15

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Tip 241: acute liver failure 2

The more common causes of acute liver failure (ALF) in a neonatal intensive care unit are from ischaemic injury (at birth or after cardiac arrest) and congestive cardiac failure. If the cause is rectified, the liver usually recovers. Other causes of ALF include:

  • inborn errors of metabolism (e.g. galactosaemia)
  • perinatal infections (e.g. hepatitis B, parvovirus)
  • haematological malignancies.

Reference: Dhawan, A., & Mieli-Vergani, G. (2005). Acute liver failure in neonates. Early Human Development; 81: 1005—1010.

Previously published: 05/05/15

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Tip 240: acute liver failure

Acute liver failure in neonates is not strictly defined. A suggestion is: “a multi-system disorder in which severe impairment of liver function, with or without encephalopathy, occurs in association with hepatocellular necrosis in a patient with no recognised underlying chronic liver disease”.

It is rare, with mortality around 70%.

Reference: Dhawan, A., & Mieli-Vergani, G. (2005). Acute liver failure in neonates. Early Human Development; 81: 1005—1010.

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