Cooling in a low-resource environment: Lost in translation

Abstract

Although cooling therapy has been the standard of care for neonatal encephalopathy (NE) in high-income countries for more than half a decade, it is still not widely used in low- and middle-income countries (LMIC), which bear 99% of the encephalopathy burden; neither is it listed as a priority research area in global health. Here we explore the major roadblocks that prevent the use of cooling in LMIC, including differences in population comorbidities, suboptimal intensive care, and the lack of affordable servo-controlled cooling devices. The emerging data from LMIC suggest that the incidence of coexisting perinatal infections in NE is no different to that in high-income countries, and that cooling can be effectively provided without tertiary intensive care and ventilatory support; however, the data on safety and efficacy of cooling are limited. Without adequately powered clinical trials, the creeping and uncertain introduction of cooling therapy in LMIC will be plagued by residual safety concerns, and any therapeutic benefit will be even more difficult to translate into widespread clinical use.

Observational study shows that it is feasible to provide neuroprotective treatment for neonatal encephalopathy in low‐income countries

“…However, a meta‐analysis on therapeutic hypothermia in low‐income countries using low‐cost cooling techniques did not show a significant reduction in neonatal mortality . It was concluded that adequately randomised controlled trials are required before cooling can be offered in low‐income countries .…”

Early EEG Grade and Outcome at 5 Years After Mild Neonatal Hypoxic Ischemic Encephalopathy

“…25,26 Because 50% of infants with HIE have mild grade encephalopathy, the burden of disability with loss of academic potential and decreased employment prospects may be greater on a global scale, with greater numbers but similar cognitive outcomes to that of moderate HIE. 27 Predicting which infants with clinically mild HIE might benefit most from intervention is a challenge. Early EEG may help, because, in our cohort, normalization of the EEG in the first 24 hours was associated with a normal outcome at 5 years.…”

Clinical hypoxic-ischemic encephalopathy score of the Iberoamerican Society of Neonatology (Siben): A new proposal for diagnosis and management

“…Therapeutic hypothermia is a therapeutic strategy with scientifically proven benefits. However, the disparity of the effectiveness of this therapy in developed and poor and/or developing countries is clear, 13 demonstrating advantages in the use of equipment with Servo control and the supply of heat by convection. 14 In three studies already published, 15,16 we have presented an alternative to the use of a device developed in São Paulo (Brazil), the Neonatflow, with Servo control and supply of heat by convection, as well as humidity and isolation through the laminar flow system.…”