Mcintyre Sarah, Badawi Nadia, Blair Eve, Nelson Karin B
Cerebral Palsy Alliance, University of Notre Dame, Darlinghurst, NSW, Australia.
Dev Med Child Neurol. 2015 Apr;57 Suppl 3:2-7. doi: 10.1111/dmcn.12725.
Neonatal encephalopathy, a clinical syndrome affecting term-born and late preterm newborn infants, increases the risk of perinatal death and long-term neurological morbidity, especially cerebral palsy. With the advent of therapeutic hypothermia, a treatment designed for hypoxic or ischaemic injury, associated mortality and morbidity rates have decreased. Unfortunately, only about one in eight neonates (95% confidence interval) who meet eligibility criteria for therapeutic cooling apparently benefit from the treatment. Studies of infants in representative populations indicate that neonatal encephalopathy is a potential result of a variety of antecedents and that asphyxial complications at birth account for only a small percentage of neonatal encephalopathy. In contrast, clinical case series suggest that a large proportion of neonatal encephalopathy is hypoxic or ischaemic, and trials of therapeutic hypothermia are specifically designed to include only infants exposed to hypoxia or ischaemia. This review addresses the differences, definitional and methodological, between infants studied and investigations undertaken, in population studies compared with cooling trials. It raises the question if there may be subgroups of infants with a clinical diagnosis of hypoxic-ischaemic encephalopathy (HIE) in whom the pathobiology of neonatal neurological depression is not fundamentally hypoxic or ischaemic and, therefore, for whom cooling may not be beneficial. In addition, it suggests approaches to future trials of cooling plus adjuvant therapy that may contribute to further improvement of care for these vulnerable neonates.
新生儿脑病是一种影响足月儿和晚期早产儿的临床综合征，会增加围产期死亡和长期神经功能障碍的风险，尤其是脑瘫。随着治疗性低温技术的出现，这种针对缺氧或缺血性损伤设计的治疗方法，相关的死亡率和发病率有所下降。不幸的是，符合治疗性降温标准的新生儿中，似乎只有约八分之一（95%置信区间）能从该治疗中获益。对具有代表性人群中婴儿的研究表明，新生儿脑病可能是多种先前因素导致的结果，出生时的窒息并发症仅占新生儿脑病的一小部分。相比之下，临床病例系列显示，很大一部分新生儿脑病是缺氧或缺血性的，而治疗性低温试验专门设计为仅纳入暴露于缺氧或缺血的婴儿。本综述探讨了在人群研究与降温试验中，所研究婴儿和所开展调查之间在定义和方法上的差异。它提出了一个问题，即临床诊断为缺氧缺血性脑病（HIE）的婴儿中，是否可能存在这样的亚组，其新生儿神经功能抑制的病理生物学本质并非缺氧或缺血性，因此降温可能对其无益。此外，它还提出了未来降温加辅助治疗试验的方法，这可能有助于进一步改善对这些脆弱新生儿的护理。
