Outcome Predictors for HIE

Combination of Early Perinatal Factors to Identify Near-Term and Term Neonates for Neuroprotection. Talati AJ, Yang W, Yolton K, et al. Journal of Perinatology (April 2005); 25: 245-250.

Objective. To determine early predictors of abnormal outcome at

24 months' age in neonates at risk for hypoxic-ischemic brain injury.

Study Design. A prospective cohort study with developmental follow-up of

24 months. Infants were selected based on risk factors, and neurologic outcome was determined. Variables affecting the outcome were evaluated with univariate and multivariate methods, and a scoring system was devised to predict adverse outcome.

Results. A total of 41 infants born

35 weeks' gestational age with possibility of hypoxic-ischemic insult were enrolled. In all, 39 (95%) had known outcomes, of whom 17 (48%) had an abnormal neurologic outcome, including five deaths. The variables within the first hour of life correlating with the adverse outcome were 1- and 5-minute Apgar scores, intubation in the delivery room and cord initial base-deficit

20 mmol. A scoring system was derived based on significant variables, and a score

5 had a 90% positive predictive value for abnormal outcome. Seizures, multiorgan failure and abnormal imaging studies were also significantly associated with abnormal outcome.

Conclusions. The proposed scoring system, being highly predictive of outcome at 24 months age, may be potentially useful in selecting subjects for preventive or therapeutic interventions to prevent or minimize neurologic morbidity due to hypoxic brain injury.

Comments. Early and accurate selection of newborns who are at risk for significant long-term neurological abnormalities consequent to hypoxic-ischemic encephalopathy will become critical as neonatologists begin to utilize evidence-based strategies to attenuate the pathophysiology of initial injury. This study prospectively identified 41 of 9260 newborn infants admitted to one hospital over 2.5 years who met 3 of the following 5 criteria: (1) one minute Apgar ≤ 3 or five minute Apgar ≤ 5; (2) pH < 7.1 or base deficit > 10 or arterial cord or newborn blood gas within first hour of life; (3) abnormal fetal monitoring; (4) high risk obstetrical history (e.g., placental abruption); and (5) abnormal neonatal neurological examination in the first 12 hours (coma, seizures, hyper- or hypotonia). An abnormal outcome at 24 months was defined as death, cerebral palsy, or Bayley MDI, PDI, or motor quotient < 70. Using a simple scoring system that graded the 5 minute Apgar, the BD, and the extent of resuscitation as 0, 1, or 2, the authors found that scores ≥ 4 and ≥ 5 had positive predictive values of 75% and 90%, respectively, for abnormal outcome. This very simple evaluation tool has the virtue of accurate identification of infants with very abnormal outcomes. On the other hand, it was not clear how many infants with abnormal outcomes might not have been identified by this score; and of course, dividing outcomes into normal and abnormal is far too simplistic. An IQ of 80 may be “normal” for one infant, but deviate much more significantly from genetic potential in another infant. MLH.

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