Title: 6 year neurodevelopmental (ND) follow up of survivors with Apgar Score (AS) of 0 at 10 minutes of life, following Selective Head Cooling (SHC) at a single center NICU.
Background: An AS of 0 at 10 minutes has been recognized as a strong predictor of mortality and neurologic morbidity in term infants. Most outcome studies in the therapeutic hypothermia era have reported normal development and mild ND delay ranging from 0-56% in survivors at 18 - 24 months of age among infants with AS of 0 at 10 minutes. One multicenter study of outcomes at 6 years reported 21% of children without moderate or severe disability.
Objective: To report ND outcomes at 6 years of age in a cohort of term babies with AS of 0 at 10 minutes of life who received intensive resuscitation (CPR/epinephrine) and underwent SHC at a single center NICU.
Design/Methods: Retrospective chart review of peripartum & perinatal variables of infants born between 2007-2012. Infants received standardized IQ testing by a psychologist (GR) using the Wechsler Preschool and Primary Scale-4. Normal IQ defined as score of ≥ 85 . ND assessments were performed by a neonatologist at 3 and 6 years (1 child seen only up to 3 years). All MRIs were reviewed by a neuroradiologist. The examiners were blinded to the infant's initial NICU clinical status.
Results: 10 infants presented with AS of 0 at 10 mins; 9 of 10 were outborn. Two died and 2 were lost to follow up. By pediatrician report, one of the latter was developing normally at 18 months. All 6 survivors were severely encephalopathic prior to SHC. Initial postnatal pH < 7.00 was present in 5 of 6 cases. The MRI was normal (n=2) and no infant had basal ganglia injury (BGI). Table 1 describes less severe MRI changes in the 4 remaining infants. None of the survivors had cerebral palsy (CP) (GMFCS classification), gross motor delay or hearing or visual deficits. Three children had normal IQ scores (107, 98, 86) and normal development or mild ND deficits ; 2 had moderately low IQs (79, 73) and ND deficits, including ADHD, language delay, working memory deficits, sensory integration problems, and anxiety. One child was intellectually deficient with severe ND deficits.
Conclusions: All surviving children had evidence of severe cardio-respiratory compromise at birth, suggestive of cerebral hypoperfusion, but none had evidence of BGI or CP at follow-up. This suggests a neuroprotective effect of SHC. However, subtle ND deficits, including ADHD, language delay, memory deficits, sensory integration problems, and anxiety, were evident in most survivors. This may reflect the less severe and more cortically located lesions noted on MRI.
