Hypoxic ischaemic encephalopathy in low resource settings—time to stop cooling?

Perinatal asphyxia is a notable cause of mortality in newborn babies and neurodevelopmental disability infancy childhood, especially low-income middle-income countries (LMICs). Therapeutic hypothermia has profoundly changed the management hypoxic ischaemic encephalopathy. This therapy standard care for neonatal encephalopathy high-income (HICs). Despite having higher burden this injury than HICs, LMICs have been slow to adopt therapeutic several reasons: non-availability expensive cooling equipment, need well equipped intensive units with trained staff, high incidence home deliveries, frequent comorbid sepsis, delayed transport referral. In past decade, there advances developing low-cost increased awareness implementation LMICs. survey across India 2017, it was found that being offered 40% public 51% private units.1Chandrasekaran M Swamy R Ramji S Shankaran Thayyil indian units: national practices.Indian Pediatr. 2017; 54: 969-970Crossref PubMed Scopus (17) Google Scholar Approximately half these centres used locally improvised methods practices differed from protocols HICs. Although single-centre trials shown good outcomes use hypothermia,2Catherine RC Ballambattu VB Adhisivam B Bharadwaj SK Palanivel C Effect on outcome term neonates ischemic encephalopathy-a randomized controlled trial.J Trop 2021; 67fmaa073Crossref (6) Scholar, 3Aker K Støen Eikenes L et al.Therapeutic hypoxic-ischaemic (THIN study): randomised trial.Arch Dis Child Fetal Neonatal Ed. 2020; 105: 405-411Crossref (12) meta-analysis done 2013 did not show any significant reduction mortality.4Pauliah SS Wade A Cady EB low- countries: systematic review meta-analysis.PLoS One. 2013; 8e58834Crossref (104) one 28 studies (15 four upper countries, seven low two countries) pooled relative risk after 0·74 (95% CI 0·67–0·80).5Abate BB Bimerew Gebremichael al.Effects death among asphyxiated hypoxic-ischemic encephalopathy: control trials.PLoS 16e0247229Crossref (14) The results (HELIX) trial are therefore surprising disappointing. multi-country, India, Sri Lanka, Bangladesh, colleagues6Thayyil Pant Montaldo P al.Hypothermia moderate or severe (HELIX): Bangladesh.Lancet Glob Health. (published online Aug 3.)https://doi.org/10.1016/S2214-109X(21)00264-3Summary Full Text PDF (27) reduce combined at 18 months encephalopathy, but significantly mortality. authors concluded should be as treatment LMICs, even when tertiary facilities available. strengths study included large powered sample size, servocontrolled device, advanced imaging techniques, adequate follow-up neurodevelopment assessments. addition overall mortality, infants group had proportions adverse such coagulopathy, longer hospital stay, inotropic support. Possible reasons worse compared HICs include inclusion proportion birthweight who were small their gestational age, more born locations outside hospital, clinical seizures enrolment, duration insult. absence enrolment predictors better following hypothermia.7Wyatt JS Gluckman PD Liu PY al.Determinants head encephalopathy.Pediatrics. 2007; 119: 912-921Crossref (261) HELIX study, MRI scans revealed white-matter approximately 80% enrolled babies, suggesting subacute hypoxia. result possibly explains neuroprotection cooling. Less 13% perinatal sentinel events, either groups. Poor maternal nutrition, anaemia, which prevalent south Asia, might contributing factor high. Optimising post-resuscitation early initiation key improving outcomes,8Davies Wassink G Bennet Gunn AJ Davidson JO Can we further optimize encephalopathy?.Neural Regen Res. 2019; 14: 1678-1683Crossref (19) inadequate. 303 extramural admitted only 11% transported ambulances.9Rathod D Bhat BV Transport sick South India: condition arrival outcome.Trop Doct. 2015; 45: 96-99Crossref within enrolled, healthy survivors discharge controls.2Catherine Is last word LMICs? public-sector hospitals cater population those patients income, generalisable bears highest However, number high-income, access optimum prenatal intrapartum resourced accredited private-sector similar benefit subpopulation, newborns whose appropriate age presence event. Hence, premature completely discourage current guidelines life support suggest given capacity provide multidisciplinary resources using clearly defined protocols.10Wyckoff MH Wyllie J Aziz al.Neonatal support: 2020 International Consensus Cardiopulmonary Resuscitation Emergency Cardiovascular Care Science recommendations.Circulation. 142: S185-S221PubMed Until data available, cannot considered carefully selected countries. Further needed identify alternative treatments neuromorbidity because Meanwhile, universal coverage high-quality antenatal along unwell will best approach We declare no competing interests. Hypothermia BangladeshTherapeutic alone. Full-Text Open Access