DOI: 10.1542/peds.2005-1524 2006;118;41Pediatrics

Sean ConnollyDeidre M. Murray, C. Anthony Ryan, Geraldine B. Boylan, Anthony P. Fitzgerald and

Video-Electroencephalographic MonitoringPrediction of Seizures in Asphyxiated Neonates: Correlation With Continuous

  

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ARTICLE

Prediction of Seizures in Asphyxiated Neonates:Correlation With Continuous Video-Electroencephalographic MonitoringDeidre M. Murray, MDa, C. Anthony Ryan, MDa, Geraldine B. Boylan, PhDa, Anthony P. Fitzgerald, PhDb, Sean Connolly, MDc

aDepartment of Pediatrics and Child Health, University College Cork, Unified Maternity Services, Cork, Ireland; bDepartment of Epidemiology, University College, Cork,Ireland; cDepartment of Clinical Neurophysiology, St Vincent’s University Hospital, Dublin, Ireland

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT

BACKGROUND.After perinatal asphyxia, predicting which infants will develop signif-icant hypoxic-ischemic encephalopathy and neonatal seizures remains a difficulttask. High-risk markers (Apgar score, acidosis, nucleated red blood cells, andresuscitation) have been used to predict neonatal seizures with varying success.The “3 strikes” of Apgar score of �5 at 5 minutes, pH �7.00, and need forintubation have been cited as having a positive predictive value of 80%. Weexamined whether the predictive values of these markers would be increased ifearly continuous electroencephalographic monitoring allowed us to accuratelyidentify all neonatal seizures and to grade the encephalopathy.

METHOD.We recruited term infants with perinatal asphyxia. Continuous video elec-troencephalography was commenced soon after birth and continued for 24 to 72hours. The abilities of high-risk markers to predict electroencephalographic sei-zurs, background electroencephalographic activity, and Sarnat grade were exam-ined.

RESULTS. Forty-nine infants were suitable for analysis. Electrographic seizures oc-curred in 11 of the 49 infants. Encephalopathy was scored by using Sarnat grade(6, severe; 18, moderate; 25, mild) and electroencephalographic findings (4 inac-tive, 4 major abnormalities, 16 moderate abnormalities, and 25 normal/mildlyabnormal). Apgar score of �5 at 5 minutes, pH �7.0, and the need for intubationhad positive predictive values for neonatal seizures of 18%, 16%, and 21%,respectively. Combining these markers gave a positive predictive value of 25% anda negative predictive value of 77%. Substituting base deficit or lactate for pH in the3-strikes model did not improve its predictive value. Apgar score of �5 at 5minutes, nucleated red blood cells, and a base deficit less than �15 mEq/L showedsome association with Sarnat grade. Only 5-minute Apgar score was significantlyassociated with both Sarnat grade and electroencephalographic grade.

CONCLUSION.After perinatal asphyxia, neither the condition at birth nor the degree ofmetabolic acidosis reliably predict neonatal seizures.

www.pediatrics.org/cgi/doi/10.1542/peds.2005-1524

doi:10.1542/peds.2005-1524

KeyWordshypoxic-ischemic encephalopathy, videoelectroencephalography, neonatalseizures, seizure prediction

AbbreviationsPPV—positive predictive valueBD—base deficitNRBC—nucleated red blood cellEEG—electroencephalographicHIE—hypoxic-ischemic encephalopathyCI—confidence interval

Accepted for publication Jan 19, 2006

Address correspondence to C. Anthony Ryan,MD, Unified Maternity Services, ErinvilleHospital, Western Road, Cork, Ireland. E-mail:ryant1@shb.ie

PEDIATRICS (ISSN Numbers: Print, 0031-4005;Online, 1098-4275). Copyright © 2006 by theAmerican Academy of Pediatrics

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AFTER PERINATAL ASPHYXIA, the occurrence of sei-zures remains a significant neurologic event. The

outlook for long-term neurologic development is changeddramatically by the occurrence of clinical seizures, whichplace the infant in the category of moderate-to-severe en-cephalopathy.1,2 The current markers of fetal distress arepoor indicators of neurologic outcome.3,4 Apgar score �5 at5 minutes, pH �7.0, and the need for intubation in thedelivery room all have individual positive predictive values(PPVs) for seizure development of 20% to 30%.5 It hasbeen reported previously, and cited frequently, that these3 indicators in combination have a much better predictivevalue, with a PPV of 80%. These factors were termed the “3strikes” by Perlman and Risser5 in the prediction of neo-natal seizures. Base deficit (BD), arterial lactate, and levelsof nucleated red blood cells (NRBCs) have also been ex-amined for their ability to predict neurologic outcome withvaried results.6–8

All of the previous studies examining the predictionof seizures were based on clinically diagnosed seizures,confirmed by intermittent electroencephalographic (EEG)recordings. However, it is now known that �60% ofneonatal seizures are subclinical and will not be recog-nized without continuous EEG monitoring.9 We haveshown recently that experienced neonatal staff will mis-diagnose clinical seizures �50% of the time.10

Continuous EEG monitoring is the gold standard foraccurate neonatal seizure detection. As part of ongoingresearch into the evolution of EEG in hypoxic-ischemicencephalopathy (HIE), we have been performing early,continuous digital video EEG in infants with this condi-tion. We wished to determine whether the ability of theclinical markers outlined above to predict neonatal sei-zures would be improved if continuous early video-EEGmonitoring allowed all of the seizures to be accuratelydetected.

METHODSThis prospective study was conducted in a large mater-nity service with an annual delivery rate of 6000. Ethicalapproval was obtained from our local hospitals ethicscommittee. From May 2003 to December 2005, infantsat high risk of HIE were recruited. Term infants (�37weeks’ gestation) were defined as high risk if they ful-filled �2 of the following criteria: (1) initial capillary orarterial pH �7.1, (2) Apgar score �5 at 5 minutes, (3)initial capillary or arterial lactate �7 mmol/L, and (4)abnormal neurology or clinical seizures.

The parents of infants fulfilling the criteria were ap-proached shortly after delivery, and written consent wasobtained. Continuous video EEG was recorded fromwithin 3 to 6 hours of birth for 24 to 72 hours. Apgarscores, delivery room resuscitation requirement, initialblood gases, and NRBC levels on day 1 of life wererecorded.

Initial blood gases were collected within 30 minutes

of delivery. Because pH, BD, and lactate do not differsignificantly between capillary and arterial sampling,11,12

these parameters were estimated from capillary blood incases where no arterial lines were in situ. Each infantwas also assigned a Sarnat score based on clinical behav-ior at 24 hours.13 Digital EEG was recorded continuouslyfrom 12 bipolar EEG channels (Taugagreining Nervusmonitor). Silver-chloride electrodes were applied to thescalp at F3, F4, C3, C4, T3, T4, P3, P4, O1, O2, and CZ(using international 10–20 system of electrode place-ment modified for neonates). Continuous digital videoimaging of the infant was recorded simultaneously.Physiologic parameters, heart rate, respiration, oxygensaturation, and (where available) direct arterial bloodpressure were recorded digitally from the infant’s inten-sive care monitor at the same time and stored with theEEG signal on the digital EEG system. Clinicians wereuntrained in EEG interpretation and blinded to EEGdata. Antiepileptic medications were administered asclinically indicated according to unit protocol.

Video EEG was analyzed visually by an experiencedneonatal neurophysiology scientist (G. B. B.) after dis-charge from the unit. Seizures were defined as repetitiverhythmic activity of �10-seconds duration with a dis-tinct beginning, middle, and end. The background activ-ity of the EEG was graded according to a standardizedgrading system described previously14 and outlined inTable 1.

Statistical AnalysisThe ability of indicators of fetal distress (pH �7.0, Apgar�5 at 5minutes, intubation in the delivery room, initiallactate, and BD and NRBC level) to predict neonatalseizures was evaluated using positive and negative pre-dictive values. The discriminatory abilities of continuousvariables (pH, BD, lactate, NRBCs, and Apgar score)were measured using area under the receiver operatorcharacteristic curves. Mann-Whitney rank sum test andnonparametric trend test were used to test associationsbetween high-risk markers and both Sarnat grade andEEG grade.

RESULTSFifty-seven term infants were enrolled in the study. Allof the infants were admitted directly to the NICU. Four

TABLE 1 Classification of EEG Background Activity

Abnormality Activity

Normal/mild abnormalities Normal pattern for GA, including slightly abnormalactivity (eg, mild asymmetries, mild voltagedepression)

Moderate abnormalities Discontinuous activity with IBI of �10 s, clearasymmetry or asynchrony

Major abnormalities IBI of 10-60 s, severe depression, no wake/sleepcycles

Inactive EEG Background activity of �10 �V, IBI of �60 s

GA indicates gestational age; IBI, interburst interval.

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infants were planned home deliveries, and accurate de-tails of Apgar scores and resuscitation were not available.These 4 infants were excluded from analysis. Of the 53remaining infants, 49 had continuous early video-EEGmonitoring. Only those infants who had continuousEEG monitoring were included in analysis. The majorityof infants (42 of 49) were enrolled at birth, and the mean(SD) time from birth to commencement of EEG moni-

toring was 5.8 (2.7) hours. Seven infants only fulfilledcriteria for enrollment after the onset of clinical seizuresand their EEG monitoring was commenced �12 hoursfrom birth. The mean (SD) birth weight of the infants was3346 (658) g, and the gestational age was 40 (1.5) weeks.

Electrographic seizures occurred in 11 (22%) of the49 infants. All of the infants had clinical signs of HIEgraded by Sarnat score: 6 severe, 18 moderate, and 25 in

TABLE 2 High-Risk Markers and Occurrence of Seizures

Case No. Resus Mode pH Lactate, mmol/L Apgar 1 Apgar 5 Seizures Sarnat Score

1 BMV 5 6.68 21.00 4 6 N 12 O2 3 7.10 7 9 N 13 O2 3 7.20 8.40 6 9 N 14 O2 5 7.14 6 7 N 15 BMV 3 7.24 4.20 5 9 Y 16 Intubation 5 7.01 6.90 0 2 Y 27 BMV 5 7.32 8.00 4 7 N 18 BMV 2 6.90 20.00 4 5 Y 29 BMV 2 6.86 13.50 1 6 N 210 None 5 7.18 1.50 4 8 N 111 Intubation 5 7.09 11.00 2 4 N 212 Intubation 2 7.20 6.70 3 6 Y 113 Intubation 5 7.03 13.50 3 5 N 114 Intubation 0 7.09 9.10 4 5 N 115 Intubation 2 7.04 12.50 6 7 Y 216 Intubation 2 7.00 19.00 6 8 Y 217 Intubation 5 6.70 17.00 0 5 N 118 Intubation 2 7.01 17.00 4 7 N 119 Intubation 5 7.09 11.50 5 6 N 120 O2 3 7.16 8.80 7 8 Y 221 Intubation 2 7.01 9.60 2 5 N 222 None 5 7.17 7.40 9 9 Y 223 BMV 0 6.88 13.30 5 7 N 124 Intubation 5 7.13 11.70 5 6 N 225 BMV 0 6.80 10.70 5 6 N 226 Intubation 2 6.99 11.70 2 4 N 227 Intubation 5 6.90 18.00 4 8 N 128 Intubation 5 6.80 16.00 2 5 N 229 None 5 7.13 9.30 8 10 N 130 BMV 1 7.06 11.60 5 7 Y 331 Intubation 5 6.95 10.90 1 7 N 232 Intubation 0 7.04 6.30 0 2 N 333 Intubation 1 6.50 20.00 1 5 N 334 BMV 1 6.80 17.00 5 5 N 135 Intubation 5 7.16 5.60 3 7 N 136 Intubation 5 6.90 13.20 7 8 N 137 BMV 2 7.03 10.40 1 7 N 138 Intubation 0 7.10 10.00 5 8 N 139 Intubation 5 7.04 10.80 2 7 N 140 BMV 2 6.99 6.30 3 7 N 141 Intubation 1 7.19 10.10 2 3 N 342 O2 5 7.09 8 8 N 243 Intubation 5 7.18 15.00 2 6 Y 244 Intubation 5 6.80 12.00 2 3 N 245 Intubation 5 7.05 12.10 4 5 N 146 None 0 7.17 11.00 6 7 N 247 Intubation 2 6.78 1 1 Y 348 Intubation 0 6.72 16.00 1 3 N 349 Intubation 5 6.95 17.00 2 6 N 1

Resus indicates resuscitation required in delivery room: O2, free-flowoxygen; BMV, bag andmask ventilation; Mode:mode of delivery: 0, normal vaginal delivery; 1, vacuum; 2, forceps; 3, forceps andvacuum; 4, elective cesarean; 5, emergency cesarean section; Apgar 1, Apgar score at 1 minute of age; Apgar 5, Apgar score at 5 minutes of age; Sarnat score: 1, mild; 2, moderate; 3, severe; N, no;Y, yes.

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the mild category. Degree of encephalopathy was alsograded by EEG findings, as follows: 4 inactive, 4 withmajor abnormalities, 16 with moderate abnormalities,and 25 normal or with mild abnormalities. The high-riskmarkers in each of the 49 infants are outlined in Table 2.Apgar scores of �5 at 5 minutes occurred in 17 (35%) of49. An initial pH of �7.0 occurred in 19 (39%) of 49.Intubation in the delivery room was required in 29(59%) of 49 infants. An initial lactate level was availablein 45 infants and was �10 mmol/L in 31 (69%) of 45infants, and BD at �15 mEq/L or more occurred in 20(41%) of 49. NRBC levels were available in 38 infantsand were �10 per 100 white blood cells in 18 (47%) of38 infants. The time from birth to initial blood gas esti-mation was �30 minutes in 41 of 49, 30 to 60 minutesin 5 of 49, and unrecorded in 3 of 49 cases.

The predictive ability of each of the high-risk markersis shown in Table 3. The individual PPVs of an Apgarscore �5 at 5 minutes, pH �7.0, and the need for intu-bation in the delivery room were 18%, 16%, and 21%,respectively. We combined 3 markers, denoted the “3strikes,” in seizure prediction to assess their combinedpredictive value in our patient group.5 Combining thesemarkers did not improve their predictive value. Of the49 infants, 8 had all 3 of the risk factors, and only 2 ofthese had seizures, giving a PPV (95% confidence inter-val [CI]) of 25% (95% CI: 3–65) and a negative predic-tive value (95% CI) of 78% (95% CI: 62–89). Thesubstitution of BD and lactate for pH in the 3 strikesmodel did not improve its predictive ability.

We also examined the occurrence of high-risk mark-ers in differing encephalopathic grades by using the clin-ical Sarnat score and the grade of EEG abnormality.Because of the small numbers of infants with severeencephalopathy, those with moderate and severe en-

cephalopathy were considered together. Of the high-riskmarkers examined, an Apgar score at 5 minutes, a raisedNRBC level, and a BD more than �15 mEq/L differedsignificantly between Sarnat grades (Table 4). Only Ap-gar score at 5 minutes showed a statistically significantassociation with EEG grade (P � .026).

Seizures were clinical and electrographical in 9 of 11cases and electrographic alone in 2 of 11. As alreadystated, 4 infants fulfilled the criteria for enrollment butdid not have continuous EEG monitoring because oftechnical reasons. In these infants, 2 had clinically sus-pected seizures and, hence, a clinical Sarnat grade ofmoderate. The remaining 2 infants had a Sarnat grade ofmild.

DISCUSSIONSupportive care has long been all that clinicians canoffer an infant after perinatal asphyxia, allowing them tofollow the clinical evolution of the encephalopathy be-fore assigning prognosis. The potential of neuroprotec-tive therapies, such as hypothermia, has raised the im-portance of accurate prediction of outcome in the first6 hours of life.15

Our results highlight the difficulty faced by research-ers and clinicians in assigning early and accurate prog-nosis to these infants. Individually, Apgar scores, acid-base disturbance, NRBCs, and the requirement forresuscitation in the delivery room did not reliably pre-dict the occurrence of seizures. Furthermore, we haveshown the lack of improvement in prediction usingcombinations of high-risk markers. This contradicts thefrequently cited 3 strikes theory of increasing seizurerisk with multiple high-risk markers. Perlman andRisser’s5 group who showed a PPV of 80% with a com-bination of Apgar score, pH �7.0, and the need forintubation in the delivery room, was based on a similarpopulation: 96 high-risk infants from a population of�15 000 births. In their group, only 5 infants had clin-ically diagnosed seizures. It is important to note thatin both groups of high-risk infants, there were verysmall numbers of infants with all 3 strikes. This makesit difficult to draw any conclusions from the predictivevalues found; however, it is unlikely to be a usefulclinical score.

We did find a statistically significant difference inApgar scores, NBRCs, and BD between infants who de-

TABLE 3 Ability of High-Risk Markers to Predict Neonatal Seizures

Risk Marker PPV, % NPV, % AUROC (95% CI)

pH �7.0 16 73 0.36 (0.17–0.56)Apgar �5 at 5 min 18 74 0.44 (0.22–0.66)Lactate �10 mmol/L 16 64 0.43 (0.19–0.67)BD less than �15 mEq/L 15 72 0.45 (0.24–0.65)NRBCs �10 per 100 WBCs 28 80 0.61 (0.38–0.85)Intubation 21 75

NPV indicates negative predictive value; AUROC, area under the receiver operator characteristiccurve; WBC, white blood cell.

TABLE 4 Comparison of High-Risk Markers Between Infants With Mild Encephalopathy and Those WithModerate-to-Severe Encephalopathy

Sarnat Score Mild, Value Moderate/Severe, Value P

pH 7.05 (6.95 to 7.14) 7.01 (6.83 to 7.05) .24Lactate, mmol/L 10.8 (8 to 17) 11.65 (10.1 to 15) .45Base deficit, mEq/L �11. (�9.3 to 15.5) �15.5 (�12.1 to�18.5) .04Apgar score at 5 min 7 (6 to 8) 5.5 (3.5 to 7) .01NRBCs, per 100 WBCs 7 (3 to 11) 16 (5 to 7) .04

A P value for a positive association was calculated using a Wilcoxon rank-sum test. Results are displayed as median (lower to upper quartiles).

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veloped mild encephalopathy and those who progressedto moderate/severe encephalopathy. The clinical signif-icance of these findings will depend on the individualphysician.

Continuous early video-EEG monitoring allowed usto improve our accuracy of seizure detection but did notimprove the predictive ability of the early clinical mea-surements. In addition, we found no improvement inpredictive value with the substitution of BD or lactate forpH in the 3 strikes model. The outcome after severeacidosis is variable. This has been shown previously andagain in our group.4 Focusing on metabolic acidosis and,in particular, lactic acidosis may identify infants at risk ofHIE but will not help in predicting the occurrence ofseizures or the grade of the encephalopathy.6,16

We should not be surprised that reactive changes toan underlying pathologic process do not give us thewhole picture. Acid-base disturbance is a secondaryevent caused by inadequate tissue perfusion and oxy-genation. Animal studies have shown that the greatestpredictor of neuronal damage is hypotension rather thanhypoxia.17 In addition, these same animal experimentsshow that only the fetal lambs that develop suppressionof their EEG during periods of induced asphyxia willdevelop cerebral damage. None of our current “earlymarkers” give us any indication of the degree of hemo-dynamic or EEG disturbance that the infant has sus-tained.

Sarnat scoring has a good predictive ability, but it cannot be assigned until 24 hours of age, too late for ben-eficial recruitment to neuroprotective therapies. In con-trast, EEG grading can be assigned soon after deliveryand offers more reliable prognosis than Sarnat scoringalone.18

EEG remains our best method of predicting neuro-logic outcome in HIE.19,20 A normal or mildly abnormalEEG in the first 24 hours of life has a PPV of 94% inpredicting a normal neurologic outcome. In contrast, aseverely abnormal or inactive EEG predicts death orsevere disability in 100% of cases. Moderate abnormal-ities will be associated with neurologic disability in�60% of cases. Unfortunately, most centers do not cur-rently have access to either the equipment or expertiserequired for prompt neonatal EEG recording and inter-pretation.

Early amplitude integrated EEG has been shown toaccurately predict the severity of encephalopathy andlong-term neurologic outcome.21 For this reason, it hasbeen used in the recruitment of infants with moderateand severe encephalopathy to clinical trials of neuropro-tective hypothermia, with promising results.15 However,amplitude integrated EEG shows poor reliability com-pared with continuous EEG when reported by inexperi-enced personnel and does not allow localization of pa-thology or seizure activity.22

CONCLUSIONSMost infants who develop HIE will have demonstratedsome evidence of perinatal distress. However, neitherthe condition at birth nor the degree of metabolic aci-dosis reliably predicts the occurrence of seizures. Thedevelopment of early and expert analysis of neonatalEEG is currently our best hope for advancement in neu-roprotective therapies and accurate outcome predictionin HIE.

ACKNOWLEDGMENTSThis study has been supported by grants from the IrishInstitute of Clinical Neuroscience and the Health Re-search Board of Ireland.

We thank the parents of the infants involved in thestudy and the nursing staff of the Unified MaternityService, Cork, for their help and enthusiasm.

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WHEN IS A BABY TOO FAT?

“New guidelines from the World Health Organization are prompting a debateover how big a healthy baby should be. The WHO, the United Nations’ healthagency, is urging every country to adopt its growth charts, which aim to showhow children ideally grow in their first five years of life. The new guidelinesalso include for the first time measurements for body mass index, or BMI, forbabies under age 2—a weight and height calculation used to determinewhether people are overweight or underweight. But the charts—and partic-ularly the new BMI standards—are raising concerns that worries aboutobesity will be pushed into infancy—a time when adequate nutrition iscrucial for brain development and other important growth. Pediatricians andhealth officials in the US say they aren’t sure whether the WHO guidelinesshould be adopted in this country. One reason is that the WHO growth curvesgenerally make US infants and toddlers look heavier than the current chartsAmerican pediatricians use. The WHO growth curves are based on babieswho were breast-fed for at least a year, while the American charts are basedon children who were primarily formula-fed after the first few weeks. For-mula-fed children tend to be bigger than breast-fed children in late infancy.(Specifically, the WHO charts are based on children from affluent, educatedfamilies in six countries. The US Charts are based on a broad sample of USchildren.) . . . About 14% of US toddlers ages 2 to 5 years old are estimated tobe overweight, according to the CDC. Currently, BMI doesn’t appear on USgrowth charts until age 2. The WHO estimates, that under its new guidelines,the number of US children from birth to age 5 who are considered overweightcould rise by as much as 30%. Babies’ weights often fluctuate in infancy,making it hard to determine whether they are too heavy or just goingthrough a growth spurt. ‘You can’t predict overweight in kids in the first sixmonths,’ says Frank Greer, professor of Pediatrics at the University of Wis-consin and chairman of the American Academy of Pediatrics’ committee onnutrition. ‘We don’t want mothers calorie-counting.’ ”

McKay B.Wall Street Journal. May 18, 2006Noted by JFL, MD

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DOI: 10.1542/peds.2005-1524 2006;118;41Pediatrics

Sean ConnollyDeidre M. Murray, C. Anthony Ryan, Geraldine B. Boylan, Anthony P. Fitzgerald and

Video-Electroencephalographic MonitoringPrediction of Seizures in Asphyxiated Neonates: Correlation With Continuous

  

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