Matteo Giampietri

Safety and efficacy of topiramate in neonates with hypoxic ischemic encephalopathy treated with hypothermia (NeoNATI)

BackgroundDespite progresses in neonatal care, the mortality and the incidence of neuro-motor disability after perinatal asphyxia have failed to show substantial improvements. In countries with a high level of perinatal care, the incidence of asphyxia responsible for moderate or severe encephalopathy is still 2–3 per 1000 term newborns. Recent trials have demonstrated that moderate hypothermia, started within 6 hours after birth and protracted for 72 hours, can significantly improve survival and reduce neurologic impairment in neonates with hypoxic-ischemic encephalopathy. It is not currently known whether neuroprotective drugs can further improve the beneficial effects of hypothermia. Topiramate has been proven to reduce brain injury in animal models of neonatal hypoxic ischemic encephalopathy. However, the association of mild hypothermia and topiramate treatment has never been studied in human newborns. The objective of this research project is to evaluate, through a multicenter randomized controlled trial, whether the efficacy of moderate hypothermia can be increased by concomitant topiramate treatment.Methods/DesignTerm newborns (gestational age ≥ 36 weeks and birth weight ≥ 1800 g) with precocious metabolic, clinical and electroencephalographic (EEG) signs of hypoxic-ischemic encephalopathy will be randomized, according to their EEG pattern, to receive topiramate added to standard treatment with moderate hypothermia or standard treatment alone. Topiramate will be administered at 10 mg/kg once a day for the first 3 days of life. Topiramate concentrations will be measured on serial dried blood spots. 64 participants will be recruited in the study. To evaluate the safety of topiramate administration, cardiac and respiratory parameters will be continuously monitored. Blood samplings will be performed to check renal, liver and metabolic balance. To evaluate the efficacy of topiramate, the neurologic outcome of enrolled newborns will be evaluated by serial neurologic and neuroradiologic examinations. Visual function will be evaluated by means of behavioural standardized tests.DiscussionThis pilot study will explore the possible therapeutic role of topiramate in combination with moderate hypothermia. Any favourable results of this research might open new perspectives about the reduction of cerebral damage in asphyxiated newborns.Trial registrationCurrent Controlled Trials ISRCTN62175998; ClinicalTrials.gov Identifier NCT01241019; EudraCT Number 2010-018627-25

A pilot study on early home-based intervention through an intelligent baby gym (CareToy) in preterm infants

BACKGROUND CareToy is an intelligent system, inspired by baby gyms, aimed to provide an intensive, individualized, home-based and family-centred early intervention (EI) program. AIMS A pilot study was carried out to explore the feasibility of CareToy intervention in preterm infants, aged 3-9 months of corrected age. METHODS Twenty low-risk preterm infants, without brain lesion or other clinical complications (14 allocated to CareToy intervention and 6 to Standard Care) were recruited. The Infant Motor Profile (IMP) was predefined as the primary outcome measure and Alberta Infant Motor Scale and Teller Acuity Cards as secondary measures. Moreover, 202 pre-programmed training scenarios were developed and instructions for the management of CareToy intervention were defined as general guidelines. OUTCOMES AND RESULTS All infants received 4 weeks of their allocated intervention and were evaluated with the selected tests before and immediately after the 4 weeks. The mean difference changes in IMP total score and Teller Acuity Cards over the intervention period were higher in the CareToy group than in the Standard Care group. CONCLUSIONS AND IMPLICATIONS CareToy seems a feasible device for providing EI. An adequately powered randomized clinical trial is warranted.

Lutein administration to pregnant women with gestational diabetes mellitus is associated to a decrease of oxidative stress in newborns

Abstract Oxidative stress (OS) is defined as an imbalance between pro- and antioxidant factors that can lead to cellular and tissue damage. Under condition of gestational diabetes, OS is exacerbated and can cause vascular dysfunction in the placenta, leading to fetal and perinatal complications. We investigated the oxidative status of diabetic pregnant women and of their babies. A group of those diabetic women received lutein, and another group did not receive anything. In order to verify a possible antioxidant function of lutein, we compared the OS values of the two groups. OS appeared lower in treated gravidas than in untreated ones; however, there was not a statistically significant difference between the two groups. As far as newborns are concerned, there was a significant difference of OS values between babies born to mothers treated with lutein and newborns to mothers untreated at 2 h of life. However, at 48 h, there was not a significant difference between the two groups. In conclusion, lutein administration during pregnancy significantly reduced neonatal OS at birth. Further studies are necessary to evaluate the effects of combined administration to mother and infants.

Safety and efficacy of topiramate in neonates with hypoxic ischemic encephalopathy treated with hypothermia (NeoNATI): a feasibility study

Abstract Purpose: To investigate the feasibility of a study based on treatment with topiramate (TPM) added to moderate hypothermia in newborns with hypoxic ischemic encephalopathy (HIE). Materials and methods: Multicenter randomized controlled trial. Term newborns with precocious metabolic, clinical and electroencephalographic (EEG) signs of HIE were selected according to their amplified integrated EEG pattern and randomized to receive either TPM (10 mg/kg once a day for the first three days of life) plus moderate hypothermia or hypothermia alone. Safety was assessed by monitoring cardiorespiratory parameters and blood samples collected to check renal, liver, metabolic balance and TPM pharmacokinetics. Efficacy was evaluated by the combined frequency of mortality and severe neurological disability as primary outcome. Incidence of magnetic resonance injury, epilepsy, blindness, hearing loss, neurodevelopment at 18–24 months of life was assessed as secondary outcomes. Results: Forty-four asphyxiated newborns were enrolled in the study. Twenty one newborns (10 with moderate and 11 with severe HIE) were allocated to hypothermia plus TPM and 23 (12 moderate and 11 severe HIE) to hypothermia. No statistically or clinically significant differences were observed for safety, primary or secondary outcomes. However, a reduction in the prevalence of epilepsy was observed in newborns co-treated with TPM. Conclusions: Results of this pilot trial suggest that administration of TPM in newborns with HIE is safe but does not reduce the combined frequency of mortality and severe neurological disability. The role of TPM co-treatment in preventing subsequent epilepsy deserves further studies.

A randomized clinical trial in preterm infants on the effects of a home-based early intervention with the 'CareToy System'

CareToy system is an innovative tele-rehabilitative tool, useful in providing intensive, individualized, home-based, family-centred Early Intervention (EI) in infants. Our aim was to evaluate, through a Randomized Clinical Trial (RCT) study, the effects of CareToy intervention on early motor and visual development in preterm infants. 41 preterm infants (range age: 3.0–5.9 months of corrected age) were enrolled and randomized into two groups, CareToy and Standard Care. 19 infants randomized in CareToy group performed a 4-week CareToy program, while 22 allocated to control group completed 4 weeks of Standard Care. Infant Motor Profile (IMP) was primary outcome measure, Alberta Infant Motor Scale (AIMS) and Teller Acuity Cards were secondary ones. Assessments were carried out at baseline (T0) and at the end of CareToy training or Standard Care period (T1). T1 was the primary endpoint. After RCT phase, 17 infants from control group carried out a 4-week CareToy program, while 18 infants from the CareToy group continued with Standard Care. At the end of this phase, infants were re-assessed at T2. In RCT phase, delta IMP total score and variation and performance sub-domains were significantly higher (P<0.050) in CareToy group if compared to Standard Care group. Similar results were found for Teller Acuity Cards, while no differences between groups were found for AIMS. No differences were found in any outcome measure results (T2-T0), between infants who started CareToy training before or after one month of standard care. This RCT study confirms the results of a previous pilot study, indicating that CareToy system can provide effective home-based EI. Trial Registration: This trial has been registered at www.clinicaltrials.gov (Identifier NCT01990183).

Lutein and Neurodevelopment in Preterm Infants

Carotenoids are pigments naturally occurring in plants, particularly in dark-green leafy vegetables such as raw spinach and cooked kale, and they have many functions in human tissues. Lutein is the dominant carotenoid found in adult and in infant brain especially in the neocortex and in the neural retina, however diet intake is needed because it cannot be synthesized in the body (Costa et al., 2013). Preterm infants have been deprived from carotenoid transfer during the last weeks of pregnancy and after birth the only sources are breast milk or oral supplementation. Concerning carotenoids, it has long been assumed that their intestinal absorption occurs by passive diffusion. Recently the high inter-individual variability in absorption observed in human studies argues in favor of the existence of putative membrane transporters of carotenoids. After uptake by the enterocyte, a substantial quantity of carotenoids up to 40% of the dietary intake is not metabolized. It is assumed that the major fraction of carotenoids are incorporated into chylomicrons that are secreted into the lymph (Reboul, 2013). Carotenoid composition of human milk changes during the first month postpartum. Lutein represents only 20% of carotenoids in colostrum but nearly 50% in mature milk. During the first month postpartum all four carotenoids (lutein, β-cryptoxanthin, lycopene, and α-carotene) decrease in the milk but lutein remains relatively elevated probably because it plays an important role for the infant (Gossage et al., 2002). Lutein concentration in breast milk correlates with mother plasma concentration and lutein intake during the third trimester of pregnancy. There is a dose-dependent response to lutein supplementation in lactating women. Previous studies (Sherry et al., 2014) demonstrated that lutein supplementation in pregnant women increases breast milk lutein concentration and provides plasma increase in their infants. Mothers who received higher doses of lutein supplementation had higher value of lutein concentration in plasma than mothers who received lower doses or placebo. However arterial cord blood lutein levels in addition to maternal plasma concentrations seem to be sex, gestational age and delivery mode dependent. Lutein levels are lower in males and in newborns delivered by cesarean section (Picone et al., 2012). However, post-mortem infant brain samples analyzed for lutein by HPLC did not show any difference in the levels of lutein between males and females (Lieblein-Boff et al., 2015). Arterial cord blood level of lutein is higher in preterm infants, especially at the early stage of the third trimester, than in term infants. It is possible to speculate that increased value of carotenoids in this period is related to the role in promoting central nervous system development. Lutein and zeaxanthin are found in the eye and are concentrated in the foveal depression of the macula. Previous studies (Vishwanathan et al., 2013) demonstrated a correlation between carotenoid macula concentration and brain value. The measure of total macular pigment may be a tool in investigating the role of lutein in cognitive functions. Retinal lutein is significantly related to lutein level in the occipital cortex. Renzi et al. (2013) found a relationship between macular pigments and visuo-motor response in humans. Carotenoids can enhance gap junctional communication in cell and can ameliorate visual function because gap junctions are crucial to light processing within the retina. Macular pigment optical density correlates with diet intake and with age (Bernstein et al., 2013). Lutein may improve neuroretinal maturation in preterm infants and it is predominant in brain development; these findings confirm that lutein is important for neurodevelopment in the infant but the mechanism is not completely clear (Lieblein-Boff et al., 2015). Post-mortem metabolomic analyses were performed on human infant brain tissues (hippocampus, frontal cortex, occipital cortex) commonly involved in learning and memory to study the interaction between nutrients, lutein, and products of cellular metabolism (e.g., nucleotides, sugars and amino acids; Lieblein-Boff et al., 2015). Fatty acids and amino acid neurotransmitters are positively correlated with lutein in infant brain. Lutein seems to promote maturation of cell membranes and cortical folding and seems to support the oligodendrocyte maturation. Furthermore lutein increases neurotransmitters GABA concentration (Lieblein-Boff et al., 2015). GABA seems to play an important role in modulating neuronal proliferation, maturation and synapse formation (Lieblein-Boff et al., 2015). These findings could explain the effects of carotenoids on cognitive functions and temporal processing speed in young (Lieblein-Boff et al., 2015). Anti-inflammatory, antioxidant and light-absorbing characteristics of carotenoids could be important for neonates especially for preterm babies to prevent the pathogenesis of common diseases of prematurity that may be related to poor neurodevelopmental outcome (e.g., necrotizing enterocolitis, retinopathy of prematurity, bronchopulmonary dysplasia; Rubin et al., 2012). Inflammation generates reactive oxygen species (ROS) that can attack DNA, RNA, lipids and proteins activating various signaling pathways that could cause diseases. In intrauterine life there is very low oxygen concentration but after birth higher levels of oxygen are available for the newborn and ROS as singlet oxygen and hydroxyl radicals are produced (Perrone et al., 2014). Lutein with a hydroxyl group attached to either ends of the molecule can react with singlet oxygen and can neutralize ROS (Figure ​(Figure1).1). Oxidative stress (OS), can increase during pregnancy, and it can lead to cellular and tissue damage. Lorenzoni et al. (2013) investigated the oxidative status of diabetic pregnant women and of their babies. Oxidative stress is lower in pregnant women receiving lutein and in their newborns than in untreated mothers and newborns showing that lutein administration during pregnancy significantly reduces neonatal OS at birth. Furthermore infants fed with lutein-supplemented formula seem to develop less severe retinopathy of prematurity (ROP) than control group and they have lower value of plasma C-reactive protein (CRP) (Rubin et al., 2012). These findings may be due to carotenoid immunomodulatory properties (Rubin et al., 2012). Manzoni et al. (2013) in a multicenter, double-blind, randomized controlled trial with lutein supplementation in preterm babies confirmed that threshold ROP incidence tended to be lower in the lutein treated vs. not treated infants. They also found that less severe forms of bronchopulmonary dysplasia (BPD) and necrotizing enterocolitis (NEC) were associated to lutein supplementation. Lutein is a bioactive compound and its potential epigenetic effect on neurodevelopment in preterm infants deserves further studies (Ferguson and Schlothauer, 2012). More studies are necessary to better understand the effects of lutein administration to mothers and newborns and the toxicity of these compounds. If beneficial effects of lutein are confirmed at the tested dosages, this compound should be considered as a potential therapy for the prevention of bronchopulmonary dysplasia, necrotizing enterocolitis and other diseases of prematurity. Figure 1 Lutein.

New techniques in the study of the brain development in newborn.

In the last few decades, the survival rates of preterm babies and full-term babies with severe diseases have increased due to advances in perinatal care. Understandably however, higher survival rates have not been accompanied by an overall reduction of morbidity, so that limitation of long-term neurodevelopmental abnormalities remains a major challenge of early care (Plaisier et al., 2014). The possibility to better predict the outcome of newborns at neurodevelopmental risk is essential to inform early intervention, to allow best allocation of resources, and to minimize long-term consequences. Unfortunately, clinicians continue to possess limited ability to predict neurodevelopmental outcomes, mainly relying, in most settings, on early findings at cranial ultrasound (cUS). Recent studies (Smyser et al., 2012) have proven the power of magnetic resonance imaging (MRI) superior to other neuroimaging modalities, including cUS, in detecting cerebral injury. Neonatal MRI provides non-invasive, high-resolution images in less than 1 h; scans are performed without sedation eliminating the risk and the costs associated to it and are not associated to radiation exposure, as for computerized tomography (CT). The application of MRI in the neonatal population is rapidly increasing, making MRI one of the key diagnostic tools for the assessment of early brain development and injury. In specific clinical groups, such as for example very preterm infants, cerebral MRI should become part of standard clinical care and should be systematically performed at term equivalent age (TEA). Accurate assessment of cortical folding at TEA provides an important marker for structural brain growth and maturation. Myelination of the posterior limb of the internal capsule (PLIC) at around 36–38 weeks gestation, identifiable on T1 but also on T2-weighted images, is another important maturational hallmark, since its presence and symmetry are very powerful in predicting motor outcome. MR imaging is superior to cUS also in detecting diffuse white matter (WM) injury. Indeed, although cystic periventricular leukomalacia is seen less often, diffuse non-cystic types of WM injury, including punctate WM lesions and diffuse excessive high signal intensity, are most frequent and are considered the leading cause of disturbed brain growth, connectivity, and functionality. The predictive power of conventional MRI in this domain remains relatively low, as it is not sensitive enough to analyze changes in microstructure; however, it is greatly enhanced by the use of advanced MR techniques targeting the WM, such as diffusion tensor imaging (DTI), that can help analyzing brain growth in extremely preterm babies in the absence of evident WM abnormalities (Ramenghi et al., 2009). Diffusion tensor imaging (DTI) is a relatively new MR modality that assesses water diffusion in biological tissues at microstructural level. The diffusion tensor describes an ellipsoid in space characterized by the diffusion eigenvalues (λ1,λ2,λ3) in the three orthogonal directions and their corresponding eigenvectors. In brain WM, axial diffusivity (λ1) is oriented along the direction of the main tracts and radial diffusivity (λ2 and λ3) is oriented perpendicular to these tracts. Average diffusivity (Dav) reflects the mean of these eigenvalues and it is an indicator of brain maturation and/or injury. Dav decreases with increasing age probably for decreasing water content and increasing complexity of WM structures with myelination. Fractional anisotropy (FA) reflects the variance of the eigenvalues, ranging from 0 (isotropic diffusion) to 1 (anisotropic). The diffusion is mainly anisotropic because the water molecules preferentially move in the direction of fascicles of axons (Adams et al., 2010). In the white and gray matter, there is similar water content but different Dav value probably because the WM is less restrictive to water motion. Brain water content decreases with increasing gestational age and this mostly increases the WM anisotropy values. This increase has also been attributed to changes in WM structure associated with histologic maturation, and it takes place at different rates in different brain areas [the main areas analyzed are in commissural tracts, the corpus callosum (CC), and in projection tracts, the corticospinal tracts (CSTs)]. Developmental changes in anisotropy of cerebral cortex reflect changes in its microstructure, such as the arborization of basal dendrites of cortical neurons, the innervation of the cortical plate by thalamocortical and cortico-cortical fibers, all processes which are important basis of later functional connectivity (Huppi and Dubois, 2006). Because there are strongly preferred directions of diffusion, it is possible to create color maps of neonatal brain with diffusion tensor post-processing techniques. The color maps are based on major orientation with red representing right–left, green representing antero–posterior, and blue representing superior–inferior anatomical directions (De Bruine et al., 2013) (Figure ​(Figure11). Figure 1 Color anisotropy maps. Preterm birth can cause white matter injuries (WMIs) and consequently can cause change in FA and diffusivity. Decreased FA in the CC of preterm babies scanned at TEA is rather common and implies less efficient transmission between the hemispheres and may lead to language problems and cognitive dysfunctions. Regions with increased FA in a preterm baby may be attributed to a loss or to an impairment of WM instead of improved WM maturation (Li et al., 2014). Disorders of motor function can be tested in clinical practice with DTI. In children with congenital hemiparesis, there are different diffusion characteristics of CSTs compared to healthy one. There is an increasing FA asymmetry and a decrease in FA value in the affected pyramidal tract. A recent extension of DTI is tractography, which is a powerful tool that offers the possibility of non-invasive identification of specific WM pathways and connections in the brain. The general principle is to connect adjacent image voxels following water diffusion. Directional coherence of the fibers in a pathway is used to determine the presence or absence of connectivity between two regions of the brain. Tracking of the fiber-trajectories is terminated when they turn of too much degrees between two successive voxels. The main regions of interest include the CSTs, the CC, and optic radiations (OR). The primary goal should be to understand the normal relationship between structural and functional networks of these structures but there are few data in preterm babies (Brown et al., 2014). Preterm birth correlates with reduced connectivity, and it is very difficult to establish normal value for all gestational ages. Maturation does not occur simultaneously in the brain infact, for example, connectivity increases earlier in the occipital lobe and then in the frontal area. The postnatal age and WMI are additional confounding factors of diffusion metrics (Pannek et al., 2014). Nevertheless, the primary difference between DTI and conventional imaging is the capability of DTI to often detect injury earlier. This could anticipate the diagnosis of brain damage and might offer advantages in the future for deciding early intervention or administration of neuroprotective agents. Further studies will be needed to confirm whether these new techniques may predict neurodevelopmental outcome and whether they are equally applicable to all the pathways of the central nervous system.

Elevated serum creatine kinase and small cerebellum prompt diagnosis of congenital muscular dystrophy due to FKRP mutations.

Fukutin-related protein (FKRP) is a putative glycosyltransferase that mediate O-linked glycosylation of the α-dystroglycan. Mutations in the FKRP gene cause a spectrum of diseases ranging from a limb girdle muscular dystrophy 2I (LGMD2I), to severe Walker-Warburg or muscle-eye-brain forms and a congenital muscular dystrophy (with or without mental retardation) termed MDC1C. This article reports on a Moroccan infant who presented at birth with moderate floppiness, high serum creatine kinase (CK) levels, and brain ultrasonograph suggestive of widening of the posterior fossa. Muscle biopsy displayed moderate dystrophic pattern with complete absence of α-distroglycan and genetic studies identified a homozygous missense variant in FKRP. Mutations in FKRP should be looked for in forms of neonatal-onset hyperCKaemia with floppiness and small cerebellum.

Serum cortisol concentrations during induced hypothermia for perinatal asphyxia are associated with neurological outcome in human infants

Abstract Birth asphyxia is a cause of neonatal death or adverse neurological sequelae. Biomarkers can be useful to clinicians in order to optimize intensive care management and communication of prognosis to parents. During perinatal adverse events, increased cortisol secretion is due to hypothalamo–pituitary–adrenal axis activation. We aimed to investigate if cortisol variations during therapeutic hypothermia are associated with neurodevelopmental outcome. We compared 18 cases (neonates with birth asphyxia) with 18 controls (healthy term newborns) and confirmed increased serum cortisol concentrations following the peri-partum adverse event. Among cases, we stratified patients according to neurological outcome at 18 months (group A – good; group B – adverse) and found that after 24 h of therapeutic hypothermia serum cortisol concentration was significantly lower in group A vs group B (28.7 ng/mL vs 344 ng/mL, *p = 0.01). In group B serum, cortisol concentration decreased more gradually during therapeutic hypothermia. We conclude that monitoring serum cortisol concentration during neonatal therapeutic hypothermia can add information to clinical evaluation of neonates with birth asphyxia; cortisol values after the first 24 h of hypothermia can be a biomarker associated with neurodevelopmental outcome at 18 months of age.

Recovery of aEEG Patterns at 24 Hours of Hypothermia Predicts Good Neurodevelopmental Outcome

Background: The clinical use of amplitude integrated electroencephalogram (aEEG) in the neonatal intensive care unit has largely increased. This method has been reported to have a very good predictive value for neurodevelopmental outcome in term neonates after perinatal asphyxia. Aim: The aim of this study was to assess the recovery of aEEG patterns during hypothermic treatment in full term asphyxiated neonates. Our working hypothesis is that children with aEEG recovery within 24 h of therapeutic hypothermia will have a normal development outcome (i.e., no or mild neurological impairment). Study design: We performed an observational prospective study on a group of asphyxiated patients admitted to our Neonatal Intensive Care Unit from April 2009 to April 2012. Results: 24 patients with moderate to severe perinatal asphyxia had an aEEG recorded for at least 72 h during hypotermia (at the beginning of the registration 13 patients presented moderate aEEG abnormalities and 11 severe aEEG abnormalities). Respectively 11 neonates with moderate aEEG abnormalities and 1 neonate with severe abnormalities normalized the aEEG pattern during the treatment. At the follow up 3 patients died during neonatal age, 5 babies developed cerebral palsy, 4 babies developed dyskinetic cerebral palsy and 12 babies did not develop any disability (babies with good outcome were those with normal aEEG pattern at 24 h). Conclusion: Recovery to a normal aEEG background pattern within the first 24 h of hypothermia after perinatal asphyxia predicts a normal outcome. Abnormal aEEG pattern persisting after 24 h correlates with poor outcome (death or cerebral palsy).