Review ArticleMelatonin in Hypoxic-Ischemic Brain Injury in Term andPreterm Babies

Justyna Paprocka ,1 Marek Kijonka,2 Beata Rzepka,3 and Maria Sokół2

1Department of Pediatric Neurology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland2Department of Medical Physics,Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology Gliwice Branch, Poland3Students’ Scientific Society, Department Pediatric Neurology, School of Medicine in Katowice, Medical University of Silesia,Katowice, Poland

Correspondence should be addressed to Justyna Paprocka; justyna.paprocka@interia.pl

Received 1 November 2018; Revised 23 January 2019; Accepted 30 January 2019; Published 20 February 2019

Academic Editor: Antonio Molina-Carballo

Copyright © 2019 Justyna Paprocka et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Melatonin may serve as a potential therapeutic free radical scavenger and broad-spectrum antioxidant. It shows neuroprotectiveproperties against hypoxic-ischemic brain injury in animal models. The authors review the studies focusing on theneuroprotective potential of melatonin and its possibility of treatment after perinatal asphyxia. Melatonin efficacy, low toxicity,and ability to readily cross through the blood-brain barrier make it a promising molecule. A very interesting thing is thedifference between the half-life of melatonin in preterm neonates (15 hours) and adults (45-60 minutes). Probably, the use ofsynergic strategies—hypothermia coupled with melatonin treatment—may be promising in improving antioxidant action. Theauthors discuss and try to summarize the evidence surrounding the use of melatonin in hypoxic-ischemic events in term andpreterm babies.

1. Introduction

Melatonin acting as a direct scavenger is able to removesinglet oxygen, superoxide anion radical, hydroperoxide,hydroxyl radical, and the lipid peroxide radical. Due tothe brain’s high utilization of oxygen; not adequate antioxi-dant defense and high amount of easily oxidizable, polyun-saturated fatty acids; and low concentration of serumantioxidants, it is especially sensitive to free radical injury[1]. Perinatal hypoxia occurs with an incidence of 2-6/1,000term births. The neurological consequences of perinatalhypoxia-ischemia may be visible in 50-75% of children suchas cerebral palsy, epilepsy, developmental delay, and hyper-activity disorder [2]. Hypoxic-ischemic brain injury is causedby a cascade of molecular reactions and mechanisms con-cerning calcium influx, free radical formation, free iron accu-mulation, nitric oxide production, and apoptosis activation.It is hypothesized that due to excessive free radical formation,the production of neurotrophic factors may be diminished

and directly influence neurogenesis. The late precursor cells(preoligodendrocytes) and immature oligodendrocytes thatpredominate in the developing periventricular white matterduring the period of highest risk for white matter damagein humans (23-32 weeks of postconceptional age) are partic-ularly susceptible to hypoxia-ischemia [2, 3]. The studies ofinjured preterm brain proved the involvement of the whitematter and the cortical and subcortical grey matter mani-fested as focal and/or diffuse lesions. The periventricularleucomalacia (PVL) as a focal lesion is seen in about 5%of children; more commonly, the changes are diffuse andcoexist with intraventricular and germinal matrix hemor-rhages [2]. According to Andiman et al., in the diffuse PVL,widespread axonal injury is usually recognized [3]. Still,little is known about the exact time of hypoxemia neededfor hypoxia to occur. Some studies focusing on specificmarkers of brain injury—S-100B calcium-binding protein,neuron-specific enolase (NSE), glial fibrillary acidic protein(GFAP), ubiquitin carboxyl-terminal hydrolase l1 (UCH-L1),

HindawiInternational Journal of EndocrinologyVolume 2019, Article ID 9626715, 11 pageshttps://doi.org/10.1155/2019/9626715

or total tau protein—evidence that astrocytes and neuronshave been damaged and the proteins are released into theblood through the increased permeability of the blood-brainbarrier [2, 3]. Due to poor specificity of cytokines, only inter-leukins IL-6 and IL-16 were correlated with HIE severity.Some authors claim that IL-6 and IL-8 as well as vascularendothelial growth factor (VEGF) may help to predictadverse neurological outcomes. However, the biomarkersspecific for perinatal hypoxia are still lacking [4, 5].

2. Melatonin Secretion in Fetus and inNeonatal Period

The rhythmic secretion of endogenous melatonin appearsaround the age of 2-3 months in term neonates [6, 7], whilenocturnal levels of melatonin may normalize even 48 hoursafter birth [8]. Preterm neonates display a delayed secretionof melatonin, which persists after correction for gestationalage up to 8 to 9 months of age [8]. Some studies suggest thatpreterm babies do not produce melatonin until at least 52weeks postconception [9]. In fetus life, melatonin is comingfrom the mother through the placenta. In the absence ofmaternal melatonin, the appearance of circadian rhythmsdepends principally on neurological maturation and verylittle on the environment [10]. Thus, short-gestation infantsmay suffer from melatonin deficiency, while full-term neo-nates may show only transient melatonin deficit. On thecontrary, according to Tordjman et al., no correlation wasfound between the gestational age and the concentrationof melatonin [11].

After birth, the neurologic network concerning the braincircuitry of melatonin secretion is immature, although thestructures like the suprachiasmatic nuclei and pineal glandare well functioning in the prenatal period [6]. Bagci et al.stated that melatonin concentration in newborns is higherafter vaginal delivery than after Caesarean section [12].Among the other factors that may influence melatonin secre-tion profile are intrauterine growth restriction, prematurerupture of the membranes (>6 hours), and preeclampsia(Karube 2001).

Human colostrum during the first 4-5 days after birthcontains colostral mononuclear cells capable of synthesizingmelatonin (autocrine synthesis). In newborns and infants,melatonin crosses the placenta and melatonin in the gastro-intestinal tract is of maternal origin. Usually, the concentra-tion of melatonin within the gastrointestinal tract is 10-100times higher than that in the blood [11]. Melatonin secretionin children can be measured not only in blood but also inurine and saliva [13]. However, this complex physiologicalprocess can be disturbed in some disorders, for example, inepilepsy or Angelman syndrome [14–16].

3. Pathophysiology of Perinatal Encephalopathy

Hypoxic-ischemic encephalopathy (HIE) comprises abnor-malities of consciousness, muscle tone, and autonomic con-trol. The connection between the stage of HIE (I-III) andclinical presentation was initially reflected by the Sarnat stag-ing system (Table 1). The Sarnat scale was introduced in 1976for grading infants with hypoxic-ischemic encephalopathybased on EEG and neurological examination [17]. Later on,in the scoring system created by Thompson, a child statusafter birth asphyxia may be referred to as mild HIE (1-10points), moderate HIE (1114 points), or severe HIE (15-22points) [18, 19]. Assigning a numeric score gives detailedinformation on the grade of intrapartum hypoxia (Table 2).

Animal models showed the cascade of events occur-ring after hypoxia-ischemia. The pathophysiology of braindysfunction in HIE in term and near-term infants is welldescribed. Acute hypoxic-ischemic event provokes acuteresponse—it starts from a rapid cell death due to necrosisso it is called a primary phase (from hypoxia and energydepletion, overactivation of glutamate receptors, andincreased fee radical formation) [2, 20–23].

Secondary energy failure (delayed or programmed celldeath) takes place 6-24 hours after a hypoxic event andlasts for days. This phase manifests itself by secondary cyto-toxic edema, cytokines’ secretion, and mitochondrial failureleading to cell death. Mitochondrial impairment (disruptionof membrane integrity, loss of membrane potential) candetermine overproduction of reactive oxygen molecules,

Table 1: Sarnat scale [17].

Stage 1 Stage 2 Stage 3

Mental state Hyperalert Lethargic or obtunded Stuporous

Cranial nerves Weak suck Weak or absent Absent

Motor Normal Mild hypotonia Severe hypotonia

Reflexes Mildly brisk Brisk Suppression

Primitive reflexes Normal Suppressed Suppression

Autonomic reflexes Sympathetic activation Parasympathetic activation Both systems suppressed

Seizures None Common Uncommon

EEG NormalFirst day low voltage, the burst suppressionpattern and multifocal electrographic seizures

Deep periodic EEG with burstsuppression pattern

Duration Less than 24 h 2-14 days Hours to weeks

Prognosis No sequelae Good prognosis if recovery is within daysMicrocephaly, psychomotor development

retardation, seizures, cerebral palsy

2 International Journal of Endocrinology

abnormal calcium homeostasis, and production of apoptoticproteins [2, 20–23].

Tertiary phase (weeks to years) means persistentinflammation, epigenetic changes, limited oligodendrocytes’maturation, impaired neurogenesis and axonal growth, andaltered synaptogenesis. According to the experimental studyon neonatal animals by Eklind et al. [24], inflammation rela-tive to hypoxia is most harmful for the developing brainwhen it appears acutely or in the chronic phase (probablybecause of a possible process of sensitization), whereas withinthe intermediate interval, it may have the opposite, protect-ing, effect. Thus, both intensity of the HIE insult and thedevelopmental stage are of importance. The newborn brainis also sensitive to iron-mediated damage.

Because accurate prediction of neurodevelopmental out-come in neonatal encephalopathy is important for clinicalmanagement and to evaluate neuroprotective therapies, theprognostic accuracy of cerebral magnetic resonance (MR)biomarkers in infants with neonatal encephalopathy is worthto be taken into account and evaluated. A very interestinginsight into hypoxic process pathology gives 31P brain spec-troscopy. As revealed, during the first days after a hypoxicevent, phosphocreatine (PCr) and adenosine triphosphate(ATP) are observed to fall down while Pi (inorganic phos-phate) increases [25–27]. Also, the low cerebral PCr/Pi ratioand the increased brain lactate are associated with a poordevelopmental outcome. According to Cheong et al. [25]and Thayyil et al. [27], the lactate/N-acetyl aspartate (Lac/-NAA) ratio on thalamic proton MRS (magnetic resonancespectroscopy) is a marker of neurodevelopmental outco-me—its high values within the first 3–4 days after birth arepredictive of poorer neurodevelopmental outcomes at 12-18months of life. Thayyil et al. compared the sensitivity andspecificity of early (1-7 days of life) and late (7-30 days of life)MRI with brain spectroscopy [27]. The authors concludedthat MR spectroscopy is more informative than brain MRIperformed in any time during the neonatal period [25, 27].

Another attempt to elucidate the complexity of thehypoxic-ischemic event was performed by Denihan et al.[26] using the metabolomic analysis. The authors applied acord blood metabolic profiling based on direct-infusionFourier-transform ion cyclotron resonance mass spectrome-try (FT-ICR/MS). The metabolites, like melatonin, leucine,

kynurenine, and 3-hydroxydodecanoic acid, allowed for dif-ferentiation between the children with perinatal asphyxiawith recovery and the children with perinatal asphyxiafollowed by hypoxic-ischemic encephalopathy. HIE itselfwas associated with some abnormalities in tryptophan andpyrimidine metabolism [26].

The extent and neuropathology of white matter lesionmay depend on fetus gestational age and severity of theinsult. Significantly affected cerebral white matter will inter-rupt afferent and efferent cortical connections. Recent patho-logical studies have reported also grey matter involvement inperinatal injury, like neuronal loss, gliosis, and reduction inthe density of pyramidal neurons (within layer 5) [3]. Suchlesion can be observed in at least one-third of PVL cases inthe basal ganglia and dentate cerebellar nuclei [28] and thal-amus [29]. Cortical neuronal damage is either seen as a directconsequence of axonal and or somal destruction or subse-quent to neuronal deafferentation [28–32].

Many MRI studies demonstrate diminished volumesof the thalamus and basal ganglia, hippocampus, and cer-ebellum [30, 31, 33, 34]. In term infants, neuronal injurywas thought to predominate over injury to the white mat-ter. However, recent assessment of the brains of terminfants suggests that the same range of grey and whitematter injury observed in preterm brains is sustained interm infants [35].

Probably, the genes involved in coagulation, inflamma-tory, and vascular pathways interacting with environmen-tal facts may influence both the incidence and severity ofcerebral injury. Polymorphisms in the Factor V Leidengene are associated with the atypical timing of IVH, sug-gesting an as-yet-unknown environmental trigger [32].The methylenetetrahydrofolate reductase (MTHFR) variantsrender neonates more vulnerable to cerebral injury in thepresence of perinatal hypoxia [2, 32]. Probably, the MTHFR677C>T polymorphism and low 5min Apgar score addi-tively increase the risk of IVH [2, 32]. Also, mutations incollagen 4A1, a major structural protein of the developingcerebral vasculature are seen.

Some of the children may experience fetal inflammatoryresponse syndrome (FIRS) in the course of preterm deliv-ery or premature and preterm rupture of the membranes(PROM). FIRS is a kind of immune system activation

Table 2: Thompson scale [19].

SignsScore

0 1 2 3

Tone Normal Hyper Hypo Flaccid

Level of consciousness Normal Hyperalert, stare Lethargic Comatose

Fits None <3/day >2/dayPosture Normal Fisting, cycling Strong distal flexion Decerebrate

Moro Normal Partial Absent

Grasp Normal Poor Absent

Suck Normal Poor Absent+/- bites

Respiration Normal Hyperventilation Brief apnea IPPV (apnea)

Respiration Normal Full, not tense Tense

3International Journal of Endocrinology

caused by IL-6 increased concentration [32]. It is still amatter of debate whether FIRS influences the response toHIE and whether HIE can induce FIRS and immune sys-tem activation [2, 32].

Originally defined in fetuses who experienced pretermlabor and preterm premature rupture of the membranes(PROM), FIRS is a unique condition characterized by thesystemic activation of the fetal innate immune system andby an elevation in fetal plasma IL-6 concentrations.

4. Perinatal Hypoxia Treatment Strategies

One of the well-known neuroprotective strategies inhypoxic-ischemic encephalopathy is moderate hypothermia(33-35 degrees Celsius) started within the first 6 hours afterbirth. Such therapeutic hypothermia is becoming a standardcare for moderate to severe neonatal encephalopathy (NICE2010) confirmed by a big clinical study (TOBY) [36, 37].Seventy-two hours of hypothermia induced by head cooling[38] or systemic cooling [36, 39] within about 6 hours ofbirth was associated with a consistent reduction in deathand neurological impairment at 18 months of age. Probably,the connection of hypothermia and pharmacological neuro-protection may be more effective. The future therapies arefocused on prevention of brain damage and enhancementof endogenous brain repair mechanisms. There are manypropositions of adjuvant therapy to supplement therapeutichypothermia. New approaches to neuroprotection addressdifferent mechanisms. The proposed pharmacological actionmay use anti-inflammatory actions (erythropoietin (theBRITE study), melatonin, and xenon), antiapoptotic actions(inhibition of nuclear factor kappa B- and c-jun N-terminalkinase), and stimulation of neurotrophic properties: eryth-ropoietin and brain-derived neurotrophic factor (BDNF)such as vascular endothelial growth factor (VEGF) andgranulocyte colony-stimulating factor (GCSF) [40–43].Among other antioxidants are allopurinol (ALBINO trial),topiramate, neuronal nitric oxide synthase (nNOS), inhibi-tors, pluronic copolymers, and cannabinoids [40–43]. Proba-bly, stem cell therapy may offer stimulation of endogenousneural cells [40–43].

5. Melatonin: Its Possibilities andPharmacokinetics in Preterm andTerm Newborns

Recently, the protective possibilities of melatonin and itsantioxidant actions have been studied in many neurodegen-erative disorders like Alzheimer’s disease, Huntington’s dis-ease, Parkinsonism, stroke, and ischemic brain injuries. Theaction of melatonin is mediated by two main receptors,MLT1 and MLT2, and an orphan receptor. The MLT1receptor is mainly expressed in the suprachiasmatic nuclei,cerebellum, hippocampus, and pars tuberalis of the pituitary[1, 8, 9, 11]. The MLT2 receptor dominates in the retina butis also found in the suprachiasmatic nuclei, hippocampus,and cerebellum [1, 8, 9, 11]. Melatonin may serve as a poten-tial therapeutic free radical scavenger and broad-spectrumantioxidant [1, 20–23].

Melatonin has neuroprotective properties againsthypoxic-ischemic brain injury in animal models (Table 3).

The melatonin actions in the central nervous system leadto the following [8, 11, 44–46]:

(i) Increasing the number of neurons in melatonin-treated animals in the CA1, CA2–CA3 areas, anddentate gyrus of the hippocampus and parietalcortex

(ii) Reduction of the expression of the glial fibrillaryacidic protein

(iii) Regulation of the expression of myelin basic proteinand oligodendrocytes’ function (regulation of myeli-nation process)

Melatonin supplementation does not suppress theendogenous secretion of melatonin but is known to aid theestablishment of appropriate circadian rhythms. After intra-venous or oral administration, melatonin is metabolized,mainly in the liver and secondarily in the kidney [11]. Whilethe pharmacokinetic profile of melatonin has been clearlydocumented in adults [47], in infants, the dosage of mela-tonin and the frequency of its administration may differthan those in adults. The exact dosage of this metabolite

Table 3: Proposed antioxidant actions of melatonin [1, 9, 44].

Melatonin

Scavenging of free radicals Hydroxyl radicals, hydrogen peroxide, singlet oxygen

Upregulating antioxidant pathwaysSuperoxide dismutase, glutathione, catalase, glutathione

peroxidase, glutathione reductase

Reduction of lipid peroxidation Excessive production of malondialdehyde

Stimulation of mitochondrial biogenesis andpromotion of the electron transport chain

Avoided mitochondrial permeability transition pore opening,decreased the number of TUNEL∗-positive cells/DNA breaks

Readily crossing both the placental andblood-brain barriers

Antiapoptotic action

Prevention of cytochrome c release, reduced or blockedcaspase-1 and caspase-3 activation, increased the

expression of anti-apoptotic proteins Bcl-2 and Bcl-xL,diminished Bad and Bax pro-apoptotic proteins,inhibited poly-ADP-ribose-polymerase cleavage

∗TUNEL: terminal deoxynucleotidyl transferase dUTP nick end labeling

4 International Journal of Endocrinology

needed for neuroprotection is still unknown. In global orfocal hypoxia-ischemia models, melatonin doses vary from1mg/kg to 50mg/kg [46]. However, in the case of the pre-term infants, the dosages cannot be extrapolated from theadult studies due to the infants’ immature liver metabolismand poor renal excretion influencing the pharmacokineticprofile [9]. Merchant et al. [9] used in their clinical studymelatonin concentrations closest to physiological adult con-centrations and observed that compared with adults andolder children, in preterm infants, the melatonin eliminationhalf-life and the clearance were prolonged and the volume ofdistribution was decreased. However, as revealed from theanimal and human data, the neuroprotective action of mela-tonin occurs at the doses much higher than the physiologicalones. Such conditions were applied by Carloni et al. [48] intheir study on the pharmacokinetics of melatonin after intra-gastric administration in preterm infants. Their main aimwas to investigate the melatonin pharmacokinetics in humannewborns at comparable doses. Thus, the authors used threedifferent doses of melatonin: 0.1, 0.5, and 5mg/kg, andextrapolated them according to the allometric evaluations[49] and the safety demonstrated by melatonin in clinicalstudies involving neonates with respiratory distress syn-drome, bronchopulmonary dysplasia, and sepsis [50–53].In such a way, they were able to cope with the main lim-itation for the use of melatonin in the neonatal clinicalsetting—the paucity of pharmacokinetic data with differentdelivery methods and dosages; however, their studied groupswere also small as in Merchant et al. [9]. A different pharma-cokinetic profile in premature newborns as compared to thatof adults [47] and that of the experimental animals was con-firmed in this study. Because melatonin is proposed as anadjunctive therapy to hypothermia for perinatal ischemicand inflammatory brain injuries [54], data from this studycan be helpful to prescribe proper dosage and frequency ofadministration for this particular population.

Not only the adjustment of dose but also the choice of aproper timing to administer melatonin is of fundamentalimportance in the case of preterm and term infants (hoursor days before or after hypoxia). During the perinatal andneonatal period, children are more exposed to oxidativestress as a consequence of the hyperoxic challenge due tothe transition from the hypoxic intrauterine environment toextrauterine life and because of their reduced antioxidantdefense mechanisms and increased susceptibility to highlytoxic hydroxyl radical species produced in such processes asinflammation, hyperoxia, hypoxia, ischemia-reperfusion,neutrophil and macrophage activation, and glutamate andfree iron release. The mitochondrial dysfunction, oxidativestress, inflammation, and cell death processes caused by aninadequate supply of ATP are involved in hypoxic-ischemicbrain injury [1, 32, 55]. Accumulating evidence indicates thatoxidative stress is implicated in the pathogenesis of manyneurological diseases, such as intraventricular hemorrhage,hypoxic-ischemic encephalopathy, and epilepsy [55]. Thus,it is possible even to talk about “oxygen radical disease ofthe newborn” or “oxygen radical diseases of neonatology”[56, 57]. The preventive and therapeutic strategies havefocused on avoiding the reactive oxygen species as well as

using antioxidants. The peculiar perinatal susceptibility tooxidative stress indicates that prophylactic use of antioxi-dants as melatonin could help to prevent or at least reduceoxidative stress-related diseases in newborns [58]. However,more studies are needed to confirm the beneficial effects ofmelatonin in oxidative stress in the perinatal period. At themoment, there are several mainly animal studies showingthe usefulness of melatonin in such applications.

6. Animal Models of Melatonin ProtectiveFunctions in Hypoxic-Ischemic Brain

The protective functions of melatonin against excitotoxicity,oxidative mitochondrial damage, inflammatory reaction,and cell death in the white matter have been studied foryears in various animal models [59], but the details of thehypoxic-ischemic injury processes as well the of the mecha-nism(s) by which melatonin is neuroprotective still remain asubject of active investigation. Resent animal studies byLin et al. [60] confirm that melatonin reduces intracerebralcellular inflammatory response and protects neurons againstischemic injury by reducing the oxidative stress, lipid per-oxidation, and radical oxygen species generation. New pos-sibilities open with the application of the spectroscopictechniques. Proton magnetic resonance spectroscopy wasapplied to study the effect of melatonin on neuropathologyin response to perinatal asphyxia in newborn lambs [61].The lactate :N-acetyl aspartate ratio was found to be muchhigher in asphyxia lambs compared with the controls, andmelatonin prevented its rise. The authors concluded thatmelatonin administered soon after birth may improve theoutcome in infants affected by asphyxia.

Carloni et al. have found out positive effects of melatoninadministration before and after hypoxia in immature rats[59]. In 2017, they showed in a neonatal rat brain increasedexpression and activity of SIRT1 (silent information regula-tor 1), reduced expression and acetylation of p53, andincreased autophagy activation [48]. In the experimentalstudy performed by Yawno et al. in a preterm fetal sheep,an increased oligodendrocyte cell number within the peri-ventricular white matter and improved CNPase+ myelinwithin the subcortical white matter were found [62].

Robertson et al. in the piglet study demonstrated thatcombination of melatonin (5mg/kg) and hypothermia(33.5°C) is more effective than any of these forms of the treat-ment alone [46]. Signorini et al. [63] investigated the possibleeffect of melatonin supplementation in a rat pump model ofhypoxic-ischemic encephalopathy and proved that hypoxiamay induce formation of desferrioxamine-chelatable freeirons in the cerebral cortex and, in consequence, increase oxi-dative stress. The latter, however, can be prevented by mela-tonin administrated before starting the ischemic procedure.

According to Alonso-Alconada et al., the treatment withmelatonin at 15mg/kg after neonatal hypoxia-ischemia led toreducing cell death, white matter demyelination, and reactiveastrogliosis in rat pumps [64, 65].

Melatonin was shown to protect against ischemia-/reper-fusion-induced oxidative damage to mitochondria in the fetalrat brain. According to an experimental study by Watanabe

5International Journal of Endocrinology

et al. performed in pregnant rats, melatonin may reverse thehypoxia-/reperfusion-induced changes measured as respira-tory control index (RCI) and thiobarbituric acid-related sub-stances (TBARS) [66]. Hutton et al. showed lower levels offractin and caspase-3 activation after melatonin administra-tion in a spiny mouse [67]. Another, already mentioned,experimental study conducted by Robertson et al. (pigletmodel of hypoxia-ischemia) discovered a positive effect onrepeated melatonin infusion on 1H MRS biomarkers (lacta-te/N-acetyl aspartate, lactate/creatinine) [46].

There are also some biochemical studies carried out inanimal models and in vitro systems focused on the chelatingproperties of melatonin. Romero et al. summarize them intheir review on the current state of knowledge related to therole of metals in the generation of free radical species and tis-sue injury and on the protective role of melatonin againstmetal-induced toxicity [68]. However, also in this area, fur-ther studies are necessary, as the authors claim, to confirmthe usefulness of melatonin against metal-induced toxicity.

7. Melatonin and the Clinical Trials

Data from the mentioned studies can be used to guidetherapeutic clinical trials of melatonin in preterm infants.Unfortunately, we currently lack clinical trials with a suffi-cient sample size to confirm the benefit of melatonin treat-ment in neonates with hypoxic-ischemic encephalopathyin hypothermia.

Table 4 presents the main results of our review of thealready performed studies or trials.

We took into account 8 reports; however, there is onlyone project concerning neonates with hypoxic-ischemicencephalopathy with melatonin adjuvant treatment whichis in line with our main subject. The data included inTable 4 show that the dosages, diagnosis, and observed clin-ical factors differ markedly in various approaches, thus, mak-ing the comparisons of the results difficult or impossible.

Aly et al. (Table 4) performed a prospective trial of 30HIE newborns randomized in the hypothermia alone andhypothermia with melatonin group on the background ofthe healthy newborns [69]. All infants were studied withrepeated EEG and brain MRI. In all babies, superoxidedismutase (SOD) and nitric oxide (NO) were measured. Mel-atonin administration to neonates with hypoxic-ischemicencephalopathy preserved the serum SOD concentration,reduced the production of NO, and ameliorated brain injury.These examinations showed also increased melatonin anddecreased NO in the hypothermia-melatonin group [69].

Gitto et al. (Table 4) carried out a series of studies in pre-term infants with melatonin adjuvant usage compared withconventional treatment [50–52]. In these works, the authorsinvolved the cases with respiratory distress syndrome andbronchopulmonary dysplasia and compared the concen-trations of the inflammatory mediators IL-6, IL-8, TNFα,and nitrite/nitrate.

There are additional two important reports concerningthe pharmacokinetic profile of melatonin in preterm infants(Table 4)—the data collected in these trials can be used toguide therapeutic clinical trials of melatonin in preterm

infants in the future. In that of Merchant et al. [9], the groupsize is small (only 18 preterm babies); however, the authorswere able to show that the dosage of melatonin for use in pre-term infants cannot be extrapolated from adult studies.Because of the postulated unpredicted bioavailability of oralmelatonin in this trial, melatonin was administered intrave-nously to 18 preterm infants (less than 31 weeks of gestation,less than 7 days old) in doses ranging from 0.04 to 0.6μg kg−1

over 0.5–6h in order to attain the physiological adult concen-trations. The results of the trial led by Carloni et al. [70] pointout the possibility to obtain and maintain neuroprotectiveconcentrations of melatonin in the blood using a single oraladministration of indolamine repeated every 12/24 h. Unfor-tunately, also in this study, the sizes of the studied groups ofchildren were small (3 × 5 newborns); however, the method-ology of the doses scaling between various approaches maybe helpful in the future.

Another challenge might be the possibility to administermelatonin antenatally in order to prevent or reduce brainhypoxic insult in preterm babies as shown in ClinicalTrials.-gov Identifier NCT01340417 [8].

8. Genetic Studies

A very interesting study on melatonin influence on neuralstem cell (NSC) functioning was conducted by Fu et al.[71]. Under hypoxic conditions, the authors showed thatmelatonin treatment may induce upregulation of Mash1,Neurog1, and NeuroD2 in the differentiated NSCs comparedwith untreated cells in hypoxia [71].

Denihan et al. worked on metabolomic biomarkers ofumbilical cord blood after hypoxic injury [26]. They checkeddifferent parameters using DI FT-ICR (Fourier-transformion cyclotron resonance spectrometry). Some metabolitesallowed for differentiation between children with perinatalasphyxia with recovery and children with perinatal asphyxiafollowed by hypoxic-ischemic encephalopathy like melato-nin, leucine, kynurenine, and 3-hydroxydodecanoic acid.HIE itself was associated with abnormalities in tryptophanand pyrimidine metabolism [26].

Children after hypoxia-ischemia brain injury oftendevelop circadian rhythm disorders. Yang et al. documentedthat mRNA and protein expressions of pineal arylalkylamineN-acetyltransferase (AANAT) and melatonin are impairedafter hypoxic damage [72]. They postulated that miR-325-3p(microRNA) may play a role of a potential downregulator ofAANAT-rate-limiting enzyme for melatonin synthesis [72].

Another interesting point is that hypoxic-ischemic-induced inflammation in preterm animals may be partiallyresponsible for blood-brain barrier disruption and whitematter injury [73–75]. Hu et al. in an experimental studyon hypoxic-ischemic brain injury in rat pups showed thatmelatonin treatment may restore decreased pericyte markers:PDGFRβ and desmin [75].

9. Conclusion

As stated above, the studies that focus on the neuroprotectivepotential of melatonin and its possibility of treatment after

6 International Journal of Endocrinology

Table4:Outcomedefinition

details

ofthestud

iesinclud

edin

thereview

.

Articletitle

Source

Pop

ulation

Melaton

ingrou

ps(n)

Non

melaton

ingrou

ps(n)

Melaton

indo

se,

route

Effectsobserved

andinvestigated

clinicalfactors

Resultof

melaton

inadjuvant

treatm

ent

“Melaton

inUse

for

Neuroprotection

inPerinatal

Asphyxia:aRando

mized

Con

trolledPilo

tStud

y”

AlyH

etal.

JPerinatol

2015;

35:186-191

Neonateswith

hypo

xic-ischem

icenceph

alop

athy

(HIE)

15HIE

newborns

15HIE

newborns;

15healthy

Totalof

50mg/kg

as5daily

enteral

doses

Serum

melaton

in,p

lasm

asuperoxide

dism

utase,

serum

nitricoxide,

electroencephalography,

magneticresonance

imaging,neurologic

evaluation

s

Positiveim

pacton

thestud

iedclinical

factors

“Increased

Levelsof

Malon

dialdehyde

and

Nitrite/N

itratein

the

Blood

ofAsphyxiated

New

borns:Reduction

byMelaton

in”

Fulia

etal.

J.PinealR

es.

2001;31:343-349

Asphyxiated

newborns

10asph

yxiated

newborns

10asph

yxiated

newborns

Totalof

80mg

as8oraldo

ses

Serum

malon

dialdehyde

andnitriate/nitrate

concentrations

Positiveim

pacton

thestud

iedclinical

factors

“Correlation

amon

gCytokines,

Broncho

pulm

onaryDysplasia

andMod

alityof

Ventilation

inPreterm

New

borns:

Improvem

ent

withMelaton

inTreatment”

Gitto

etal.

J.PinealR

es.2005;

39:287-293

Preterm

infants

withrespiratory

distress

synd

rome

55preterm

infants

55preterm

infants

Totalof

100mg/kg

as10

infusion

s

Interleukinmeasurements

(IL-6,IL-8,and

TNFα

)

Positiveim

pacton

thestud

iedclinical

factors

“Oxidative

andInflam

matory

Param

etersin

Respiratory

DistressSynd

romeof

Preterm

New

borns:

BeneficialEffects

ofMelaton

in”

Gitto

etal.

Amer

JPerinatol

2004;

21(4):209-2016

Preterm

infants

withrespiratory

distress

synd

rome

40preterm

infants

34preterm

infants

Totalof

100mg/kg

as10

infusion

s

Inflam

matorymediators

(IL-6,IL-8,T

NFα

,and

nitrite/nitrate)

measurements

Positiveim

pacton

thestud

iedclinical

factors

“EarlyIndicatorsof

Chron

icLu

ngDisease

inPreterm

InfantswithRespiratory

DistressSynd

romeandTheir

Inhibition

byMelaton

in”

Gitto

etal.

J.PinealR

es.2004;

36(4):250-5

Preterm

infants

withrespiratory

distress

synd

rome

60preterm

infants

60preterm

infants

Totalof

100mg/kg

as10

infusion

s

Inflam

matorymediators

(IL-6,IL-8,T

NFα

,and

nitrite/nitrate)

measurements

Positiveim

pacton

thestud

iedclinical

factors

“Pharm

acokineticsof

Melaton

inin

Preterm

Infants”

Merchantetal.

BrJClin

Pharm

acol

2013;76:725733.

Preterm

infants

18preterm

infants

Totalof

0.04-0.6μg/kg

over

0.5-6has

infusion

Pharm

acokinetic

profi

les

Positiveim

pacton

thestud

iedclinical

factors

“Melaton

inas

aNovel

Neuroprotectant

inPreterm

Infants—

aDou

ble

Blin

dedRando

mised

Con

trolledTrial

(MIN

TStud

y)”

Merchantetal.

ArchDisChild

2014:

99(Sup

pl2):A1-A620

Preterm

infants

30preterm

infants

28preterm

infants

Totalof

0.2μg/kg

over

2has

infusion

Fraction

alanisotropy

onmagneticresonance

imaging

Noeffecton

the

stud

iedclinical

factorshasbeen

observed

7International Journal of Endocrinology

Table4:Con

tinu

ed.

Articletitle

Source

Pop

ulation

Melaton

ingrou

ps(n)

Non

melaton

ingrou

ps(n)

Melaton

indo

se,

route

Effectsobserved

andinvestigated

clinicalfactors

Resultof

melaton

inadjuvant

treatm

ent

“Melaton

inPharm

acokinetics

FollowingOralA

dministration

inPreterm

Neonates”

Carloni

etal.

Molecules

2017;

22,2115

Preterm

infants

5preterm

infants

withlowdo

se,

5preterm

infants

withmedium

dose,5

preterm

infantswithhigh

dose

Totalof

0.5mg/kg

or3mg/kg

or15

mg/kg

as1

or3intragastric

boluses

Pharm

acokinetic

profi

les

Positiveim

pacton

thestud

iedclinical

factors

8 International Journal of Endocrinology

perinatal asphyxia in humans are scarce. The melatoninadvantages—its efficacy, low toxicity, and ability to readilycross through the blood-brain barrier—make it a promisingmolecule. A very interesting thing is the difference betweenthe half-life of melatonin in preterm neonates (15 hours)and adults (45-60 minutes). Hypoxic-ischemic insult leadsto devastating neurological consequences—that is why thereis a quest for other therapies complementary to the thera-peutic hypothermia (in term infants). Such novel approachesare still necessary, but they require to be validated in ran-domized trials. Probably, the synergic strategies coupledwith melatonin treatment may be promising options improv-ing antioxidant action.

Conflicts of Interest

The authors declare no conflict of interest.

References

[1] Y. C. Chen, Y. L. Tain, J. M. Sheen, and L. T. Huang, “Melato-nin utility in neonates and children,” Journal of the FormosanMedical Association, vol. 111, no. 2, pp. 57–66, 2012.

[2] A. J. Muller and J. D. Marks, “Hypoxic ischemic brain injury:potential therapeutic interventions for the future,” NeoRe-views, vol. 15, no. 5, pp. e177–e186, 2014.

[3] S. E. Andiman, R. L. Haynes, F. L. Trachtenberg et al., “Thecerebral cortex overlying periventricular leukomalacia: analy-sis of pyramidal neurons,” Brain Pathology, vol. 20, no. 4,pp. 803–814, 2010.

[4] L. F. Chalak, P. J. Sanchez, B. Adams-Huet, A. R. Laptook,R. J. Heyne, and C. R. Rosenfeld, “Biomarkers for severityof neonatal hypoxic-ischemic encephalopathy and outcomesin newborns receiving hypothermia therapy,” The Journal ofPediatrics, vol. 164, no. 3, pp. 468–474.e1, 2014.

[5] B. H. Walsh, G. B. Boylan, V. Livingstone, L. C. Kenny, E. M.Dempsey, and D. M. Murray, “Cord blood proteins andmultichannel-electroencephalography in hypoxic-ischemicencephalopathy∗,” Pediatric Critical Care Medicine, vol. 14,no. 6, pp. 621–630, 2013.

[6] J. E. Jan, M. B. Wasdell, R. D. Freeman, and M. Bax, “Evidencesupporting the use of melatonin in short gestation infants,”Journal of Pineal Research, vol. 42, no. 1, pp. 22–27, 2007.

[7] J. C. Commentz, A. Henke, O. Dammann, H. H. Hellwege, andR. P. Willig, “Decreasing melatonin and 6-hydroxymelatoninsulfate excretion with advancing gestational age in pretermand term newborn male infants,” European Journal of Endocri-nology, vol. 135, no. 2, pp. 184–187, 1996.

[8] V. Biran, A. Phan Duy, F. Decobert, N. Bednarek, C. Alberti,and O. Baud, “Is melatonin ready to be used in preterm infantsas a neuroprotectant?,” Developmental Medicine and ChildNeurology, vol. 56, no. 8, pp. 717–723, 2014.

[9] N. M. Merchant, D. V. Azzopardi, A. F. Hawwa et al., “Phar-macokinetics of melatonin in preterm infants,” British Journalof Clinical Pharmacology, vol. 76, no. 5, pp. 725–733, 2013.

[10] S. Gertner, C. W. Greenbaum, A. Sadeh, Z. Dolfin, L. Sirota,and Y. Ben-Nun, “Sleep–wake patterns in preterm infantsand 6 month’s home environment: implications for early cog-nitive development,” Early Human Development, vol. 68, no. 2,pp. 93–102, 2002.

[11] S. Tordjman, S. Chokron, R. Delorme et al., “Melatonin: phar-macology, functions and therapeutic benefits,” Current Neuro-pharmacology, vol. 15, no. 3, pp. 434–443, 2017.

[12] S. Bagci, A. L. Berner, J. Reinsberg et al., “Melatonin concen-tration in umbilical cord blood depends on mode of delivery,”Early Human Development, vol. 88, no. 6, pp. 369–373, 2012.

[13] E. A. de Almeida, P. Di Mascio, T. Harumi et al., “Measure-ment of melatonin in body fluids: standards, protocols andprocedures,” Child's Nervous System, vol. 27, no. 6, pp. 879–891, 2010.

[14] J. Paprocka, M. Kijonka, M. Pęcka, and M. Sokół, “Melatoninin epilepsy: a new mathematical model of diurnal secretion,”International Journal of Endocrinology, vol. 2016, Article ID3861461, 8 pages, 2016.

[15] J. Paprocka, M. Kijonka, Ł. Boguszewicz, and M. Sokół, “Mel-atonin in tuberous sclerosis complex analysis using modernmathematical modeling methods,” International Journal ofEndocrinology, vol. 2017, Article ID 8234502, 7 pages, 2017.

[16] J. Paprocka, M. Kijonka, P. Wojcieszek, M. Pęcka,E. Emich-Widera, and M. Sokół, “Melatonin and Angelmansyndrome – implications and mathematical model of diurnalsecretion.,” International Journal of Endocrinology, vol. 2017,Article ID 5853167, 12 pages, 2017.

[17] H. B. Sarnat and M. S. Sarnat, “Neonatal encephalopathy fol-lowing fetal distress,” Archives of Neurology, vol. 33, no. 10,pp. 696–705, 1976.

[18] D. K. Bhagwani, M. Sharma, S. Dolker, and S. Kothapalli, “Tostudy the correlation of Thompson scoring in predicting earlyneonatal outcome in post asphyxiated term neonates,” Journalof Clinical and Diagnostic Research, vol. 10, no. 11, 2016.

[19] C. M. Thompson, A. S. Puterman, L. L. Linley et al., “The valueof a scoring system for hypoxic ischaemic encephalopathy inpredicting neurodevelopmental outcome,” Acta Paediatrica,vol. 86, no. 7, pp. 757–761, 1997.

[20] B. J. Dixon, C. Reis, W. M. Ho, J. Tang, and J. H. Zhang, “Neu-roprotective strategies after neonatal hypoxic ischemicencephalopathy,” International Journal of Molecular Sciences,vol. 16, no. 9, pp. 22368–22401, 2015.

[21] K. J. Hassell, M. Ezzati, D. Alonso-Alconada, D. J. Hausenloy,and N. J. Robertson, “New horizons for newborn brain protec-tion: enhancing endogenous neuroprotection,” Archives ofDisease in Childhood - Fetal and Neonatal Edition, vol. 100,no. 6, pp. F541–F552, 2015.

[22] M. Hendaus, F. Jomha, and A. Alhammadi, “Melatonin in themanagement of perinatal hypoxic-ischemic encephalopathy:light at the end of the tunnel?,” Neuropsychiatric Disease andTreatment, vol. 12, pp. 2473–2479, 2016.

[23] K. Martinello, A. R. Hart, S. Yap, S. Mitra, and N. J. Robertson,“Management and investigation of neonatal encephalopathy:2017 update,” Archives of Disease in Childhood - Fetal andNeonatal Edition, vol. 102, no. 4, pp. F346–F358, 2017.

[24] S. Eklind, C. Mallard, P. Arvidsson, and H. Hagberg, “Lipo-polysaccharide induces both a primary and a secondary phaseof sensitization in the developing rat brain,” PediatricResearch, vol. 58, no. 1, pp. 112–116, 2005.

[25] J. L. Cheong, E. B. Cady, J. Penrice, J. S. Wyatt, I. J. Cox,and N. J. Robertson, “Proton MR spectroscopy in neonateswith perinatal cerebral hypoxic-ischemic injury: metabolitepeak-area ratios, relaxation times, and absolute concentra-tions,” American Journal of Neuroradiology, vol. 27, no. 7,pp. 1546–1554, 2006.

9International Journal of Endocrinology

[26] N. M. Denihan, J. A. Kirwan, B. H. Walsh et al., “Untargetedmetabolomic analysis and pathway discovery in perinatalasphyxia and hypoxic-ischaemic encephalopathy,” Journal ofCerebral Blood Flow & Metabolism, vol. 39, no. 1, pp. 147–162, 2017.

[27] S. Thayyil, M. Chandrasekaran, A. Taylor et al., “Cerebralmagnetic resonance biomarkers in neonatal encephalopathy:a meta-analysis,” Pediatrics, vol. 125, no. 2, pp. e382–e395,2010.

[28] C. R. Pierson, R. D. Folkerth, S. S. Billiards et al., “Gray matterinjury associated with periventricular leukomalacia in the pre-mature infant,” Acta Neuropathologica, vol. 114, no. 6,pp. 619–631, 2007.

[29] P. Ligam, R. L. Haynes, R. D. Folkerth et al., “Thalamic damagein periventricular leukomalacia: novel pathologic observationsrelevant to cognitive deficits in survivors of prematurity,” Pedi-atric Research, vol. 65, no. 5, pp. 524–529, 2009.

[30] T. E. Inder, S. J. Wells, N. B. Mogridge, C. Spencer, and J. J.Volpe, “Defining the nature of the cerebral abnormalities inthe premature infant: a qualitative magnetic resonance imag-ing study,” The Journal of Pediatrics, vol. 143, no. 2, pp. 171–179, 2003.

[31] T. Inder, J. Neil, C. Kroenke, S. Dieni, B. Yoder, and S. Rees,“Investigation of cerebral development and injury in theprematurely born primate by magnetic resonance imagingand histopathology,” Developmental Neuroscience, vol. 27,no. 2-4, pp. 100–111, 2005.

[32] S. Rees, R. Harding, and D. Walker, “The biological basis ofinjury and neuroprotection in the fetal and neonatal brain,”International Journal of Developmental Neuroscience, vol. 29,no. 6, pp. 551–563, 2011.

[33] M. Allin, H. Matsumoto, A. M. Santhouse et al., “Cognitiveand motor function and the size of the cerebellum in adoles-cents born very pre-term,” Brain, vol. 124, no. 1, pp. 60–66,2001.

[34] E. B. Isaacs, A. Lucas, W. K. Chong et al., “Hippocampal vol-ume and everyday memory in children of very low birthweight,” Pediatric Research, vol. 47, no. 6, pp. 713–720, 2000.

[35] S. Iwata, A. Bainbridge, T. Nakamura et al., “Subtle white mat-ter injury is common in term-born infants with a wide range ofrisks,” International Journal of Developmental Neuroscience,vol. 28, no. 7, pp. 573–580, 2010.

[36] D. V. Azzopardi, B. Strohm, A. D. Edwards et al., “Moderatehypothermia totreat perinatal asphyxial encephalopathy,”New England Journal of Medicine, vol. 361, no. 14, pp. 1349–1358, 2009.

[37] H. Campbell, O. Eddama, D. Azzopardi, A. D. Edwards,B. Strohm, and O. Rivero-Arias, “Hypothermia for perinatalasphyxia: trial-based quality of life at 6-7 years,” Archives ofDisease in Childhood, vol. 103, no. 7, pp. 654–659, 2018.

[38] P. Gluckman, J. Wyatt, D. Azzopardi et al., “Selective headcooling with mild systemic hypothermia after neonatalencephalopathy: multicentre randomised trial,” The Lancet,vol. 365, no. 9460, pp. 663–670, 2005.

[39] S. Shankaran, A. R. Laptook, R. A. Ehrenkranz et al., “Whole--body hypothermia for neonates with hypoxic–ischemicencephalopathy,” New England Journal of Medicine, vol. 353,no. 15, pp. 1574–1584, 2005.

[40] S. E. Juul and D. M. Ferriero, “Pharmacologic neuroprotectivestrategies in neonatal brain injury,” Clinics in Perinatology,vol. 41, no. 1, pp. 119–131, 2014.

[41] D. Kelen and N. J. Robertson, “Experimental treatments forhypoxic ischaemic encephalopathy,” Early Human Develop-ment, vol. 86, no. 6, pp. 369–377, 2010.

[42] J. Nair and V. Kumar, “Current and emerging therapies in themanagement of hypoxic ischemic encephalopathy in neo-nates,” Children, vol. 5, no. 7, 2018.

[43] K. L. Shea and A. Palanisamy, “What can you do to protect thenewborn brain?,” Current Opinion in Anaesthesiology, vol. 28,no. 3, pp. 261–266, 2015.

[44] R. Praninskiene, I. Dumalakiene, R. Kemezys, M. Mauricas,and A. Jucaite, “Diurnal melatonin patterns in children: readyto apply in clinical practice?,” Pediatric Neurology, vol. 46,no. 2, pp. 70–76, 2012.

[45] E. Gitto, L. Marseglia, S. Manti et al., “Protective role of mela-tonin in neonatal diseases,” Oxidative Medicine and CellularLongevity, vol. 2013, Article ID 980374, 6 pages, 2013.

[46] N. J. Robertson, S. Faulkner, B. Fleiss et al., “Melatonin aug-ments hypothermic neuroprotection in a perinatal asphyxiamodel,” Brain, vol. 136, no. 1, pp. 90–105, 2013.

[47] N. G. Harpsøe, L. P. H. Andersen, I. Gögenur, andJ. Rosenberg, “Clinical pharmacokinetics of melatonin: a sys-tematic review,” European Journal of Clinical Pharmacology,vol. 71, no. 8, pp. 901–909, 2015.

[48] S. Carloni, F. Proietti, M. Rocchi et al., “Melatonin pharmaco-kinetics following oral administration in preterm neonates,”Molecules, vol. 22, no. 12, p. 2115, 2017.

[49] A. B. Nair and S. Jacob, “A simple practice guide for dose con-version between animals and human,” Journal of Basic andClinical Pharmacy, vol. 7, no. 2, pp. 27–31, 2016.

[50] E. Gitto, R. J. Reiter, A. Amodio et al., “Early indicators ofchronic lung disease in preterm infants with respiratory dis-tress syndrome and their inhibition by melatonin,” Journal ofPineal Research, vol. 36, no. 4, pp. 250–255, 2004.

[51] E. Gitto, R. J. Reiter, S. P. Cordaro et al., “Oxidative andinflammatory parameters in respiratory distress syndromeof preterm newborns: beneficial effects of melatonin,” Amer-ican Journal of Perinatology, vol. 21, no. 4, pp. 209–216,2004.

[52] E. Gitto, R. J. Reiter, G. Sabatino et al., “Correlation amongcytokines, bronchopulmonary dysplasia andmodality of venti-lation in preterm newborns: improvement with melatonintreatment,” Journal of Pineal Research, vol. 39, no. 3,pp. 287–293, 2005.

[53] E. Gitto, M. Karbownik, R. J. Reiter et al., “Effects of melatonintreatment in septic newborns,” Pediatric Research, vol. 50,no. 6, pp. 756–760, 2001.

[54] Thrasher Research Fund, University of Florida,Melatonin as aNeuroprotective Therapy in Neonates with HIE UndergoingHypothermia, National Library of Medicine, Bethesda, MD,USA, 2015, Accessed October 2015, https://clinicaltrials.gov/show/NCT02621944.

[55] S. Perrone, L. M. Tataranno, G. Stazzoni, L. Ramenghi, andG. Buonocore, “Brain susceptibility to oxidative stress in theperinatal period,” The Journal of Maternal-Fetal & NeonatalMedicine, vol. 28, Supplement 1, pp. 2291–2295, 2015.

[56] O. D. Saugstad, “Oxidative stress in the newborn: a 30-yearperspective,” Biology of the Neonate, vol. 88, no. 3, pp. 228–236, 2005.

[57] O. D. Saugstad, “Hypoxanthine as an indicator of hypoxia: itsrole in health and disease through free radical production,”Pediatric Research, vol. 23, no. 2, pp. 143–150, 1988.

10 International Journal of Endocrinology

[58] E. Gitto, S. Pellegrino, P. Gitto, I. Barberi, and R. J. Reiter,“Oxidative stress of the newborn in the pre- and postnatalperiod and the clinical utility of melatonin,” Journal of PinealResearch, vol. 46, no. 2, pp. 128–139, 2009.

[59] S. Carloni, S. Perrone, G. Buonocore, M. Longini, F. Proietti,andW. Balduini, “Melatonin protects from the long-term con-sequences of a neonatal hypoxic-ischemic brain injury in rats,”Journal of Pineal Research, vol. 44, no. 2, pp. 157–164, 2008.

[60] Y. Lin, T. Chen, C. Hung et al., “Melatonin protects brainagainst ischemia/reperfusion injury by attenuating endoplas-mic reticulum stress,” International Journal of Molecular Med-icine, vol. 42, pp. 182–192, 2018.

[61] J. D. S. Aridas, T. Yawno, A. E. Sutherland et al., “Systemic andtransdermal melatonin administration prevents neuropathol-ogy in response to perinatal asphyxia in newborn lambs,” Jour-nal of Pineal Research, vol. 64, no. 4, article e12479, 2018.

[62] T. Yawno, M. Mahen, J. Li, M. C. Fahey, G. Jenkin, and S. L.Miller, “The beneficial effects of melatonin administration fol-lowing hypoxia-ischemia in preterm fetal sheep,” Frontiers inCellular Neuroscience, vol. 11, 2017.

[63] C. Signorini, L. Ciccoli, S. Leoncini et al., “Free iron, totalF-isoprostanes and total F-neuroprostanes in a model of neo-natal hypoxic-ischemic encephalopathy: neuroprotective effectof melatonin,” Journal of Pineal Research, vol. 46, no. 2,pp. 148–154, 2009.

[64] D. Alonso-Alconada, A. Álvarez, O. Arteaga, A. Martínez-Ibargüen, and E. Hilario, “Neuroprotective effect of melatonin:a novel therapy against perinatal hypoxia-ischemia,” Interna-tional Journal of Molecular Sciences, vol. 14, no. 5, pp. 9379–9395, 2013.

[65] D. Alonso-Alconada, A. Alvarez, J. Lacalle, and E. Hilario,“Histological study of the protective effect of melatonin onneural cells after neonatal hypoxia-ischemia,” Histology andHistopathology, vol. 27, no. 6, pp. 771–783, 2012.

[66] K. Watanabe, A. Wakatsuki, K. Shinohara, N. Ikenoue,K. Yokota, and T. Fukaya, “Maternally administered melato-nin protects against ischemia and reperfusion-induced oxida-tive mitochondrial damage in premature fetal rat brain,”Journal of Pineal Research, vol. 37, no. 4, pp. 276–280, 2004.

[67] L. C. Hutton, M. Abbass, H. Dickinson, Z. Ireland, and D. W.Walker, “Neuroprotective properties of melatonin in a modelof birth asphyxia in the spiny mouse (Acomys cahirinus),”Developmental Neuroscience, vol. 31, no. 5, pp. 437–451, 2009.

[68] A. Romero, E. Ramos, C. de Los Rios, J. Egea, J. Del Pino, andR. J. Reiter, “A review of metal-catalyzed molecular damage:protection by melatonin,” Journal of Pineal Research, vol. 56,no. 4, pp. 343–370, 2014.

[69] H. Aly, H. Elmahdy, M. El-Dib et al., “Melatonin use for neu-roprotection in perinatal asphyxia: a randomized controlledpilot study,” Journal of Perinatology, vol. 35, no. 3, pp. 186–191, 2015.

[70] S. Carloni, G. Riparini, G. Buonocore, andW. Balduini, “Rapidmodulation of the silent information regulator 1 by melatoninafter hypoxia-ischemia in the neonatal rat brain,” Journal ofPineal Research, vol. 63, no. 3, 2017.

[71] J. Fu, S. D. Zhao, H. J. Liu et al., “Melatonin promotes prolifer-ation and differentiation of neural stem cells subjected to hyp-oxia in vitro,” Journal of Pineal Research, vol. 51, no. 1,pp. 104–112, 2011.

[72] Y. Yang, B. Sun, J. Huang et al., “Up-regulation of mi-R-325-3psuppresses pineal aralkylamine N-acetyltransferase (Aanat)

after neonatal hypoxia-ischemia brain injury in rats,” BrainResearch, vol. 1668, pp. 28–35, 2017.

[73] M. Colella, V. Biran, and O. Baud, “Melatonin and the new-born brain,” Early Human Development, vol. 102, pp. 1–3,2016.

[74] F. Fulia, E. Gitto, S. Cuzzocrea et al., “Increased levels of mal-ondialdehyde and nitrite/nitrate in the blood of asphyxiatednewborns: reduction by melatonin,” Journal of PinealResearch, vol. 31, no. 4, pp. 343–349, 2001.

[75] Y. Hu, Z. Wang, S. Pan et al., “Melatonin protects againstblood-brain barrier damage by inhibiting the TLR4/NF-κB sig-naling pathway after LPS treatment in neonatal rats,”Oncotar-get, vol. 8, no. 19, pp. 31638–31654, 2017.

11International Journal of Endocrinology

Stem Cells International

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

MEDIATORSINFLAMMATION

of

EndocrinologyInternational Journal of

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

Disease Markers

Hindawiwww.hindawi.com Volume 2018

BioMed Research International

OncologyJournal of

Hindawiwww.hindawi.com Volume 2013

Hindawiwww.hindawi.com Volume 2018

Oxidative Medicine and Cellular Longevity

Hindawiwww.hindawi.com Volume 2018

PPAR Research

Hindawi Publishing Corporation http://www.hindawi.com Volume 2013Hindawiwww.hindawi.com

The Scientific World Journal

Volume 2018

Immunology ResearchHindawiwww.hindawi.com Volume 2018

Journal of

ObesityJournal of

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

Computational and Mathematical Methods in Medicine

Hindawiwww.hindawi.com Volume 2018

Behavioural Neurology

OphthalmologyJournal of

Hindawiwww.hindawi.com Volume 2018

Diabetes ResearchJournal of

Hindawiwww.hindawi.com Volume 2018

Hindawiwww.hindawi.com Volume 2018

Research and TreatmentAIDS

Hindawiwww.hindawi.com Volume 2018

Gastroenterology Research and Practice

Hindawiwww.hindawi.com Volume 2018

Parkinson’s Disease

Evidence-Based Complementary andAlternative Medicine

Volume 2018Hindawiwww.hindawi.com

Submit your manuscripts atwww.hindawi.com