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Fluid restriction in moderate and severe hypoxemic-ischemic encephalopathy: more evidence is needed

Journal of Perinatology volume 39, pages 342–343 (2019)Cite this article

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To the Editor:

We read the article by Tanigasalam et al. [1] with great interest. We would like to appreciate and applaud them for pioneering the work on fluid restriction in infants with moderate to severe hypoxemic-ischemic encephalopathy (HIE). However, we would like to highlight few points, clarification of which will be useful for the readers.

  1. 1.

    The occurrence of clinical seizure was a universal finding in this study. Previous studies have shown that the incidence of seizure (clinical as well as electroconvulsive) in moderate to severe HIE is 30–35% [2]. Furthermore, therapeutic hypothermia (TH) decreases the risk of seizures [2, 3]. So, the universal occurrence of clinical seizure in the study participants is very unusual finding. Such a high burden of seizures will worsen the neurodevelopmental outcome in both the groups and will take the effect towards null difference. This may have contributed to the non-significant difference between the groups in the primary outcome.

  2. 2.

    The meta-analysis has shown that TH, being the best available strategy for HIE at present, is able to reduce the death or major disability by 25% only [2]. Here, both the groups were receiving TH, still assuming that fluid restriction alone will furthermore lead to 30% better outcome is over-optimistic. This over-optimistic hypothesis led to a reduction in sample size, therefore, the study became underpowered to detect a difference of 17%.

  3. 3.

    In this study, 8% of babies in the standard group and 5% in the intervention group had abnormal retinopathy of prematurity (ROP) screen. Such a high incidence in term babies with minimal ventilation (24–48 h) is quite unusual. Therefore, it will be important to know the definition of the "abnormal ROP screen" used in the study.

  4. 4.

    The study was based on the hypothesis that the fluid restriction will reduce cerebral edema, but no steps (MRI/USG) were taken to measure this effect. Also, TH is still considered as an experimental intervention in neonates in India and around 90% of the centers prefer to do MRI in all the babies undergoing TH [4]. So, it should have been included as one of the outcome indicators.

  5. 5.

    In the intervention group, more babies had hypoglycemia, polycythemia, and abnormal neurodevelopmental outcome. Intrauterine growth restriction (IUGR) is an independent risk factor for all of these outcomes [5]. Therefore, it will be important to know the number of IUGR babies in both the groups.

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References

  1. Tanigasalam V, Plakkal N, Vishnu Bhat B, Chinnakali P. Does fluid restriction improve outcomes in infants with hypoxic-ischemic encephalopathy? a pilot randomized controlled trial. J Perinatol. 2018. https://doi.org/10.1038/s41372-018-0223-7.

  2. Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev. 2013;1:CD003311.

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  3. Gano D, Orbach SA, Bonifacio SL, Glass HC. Neonatal seizures and therapeutic hypothermia for hypoxic-ischemic encephalopathy. Mol Cell Epilepsy. 2014;1:pii: e88. https://doi.org/10.14800/mce.88.

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  4. Chandrasekaran M, Swamy R, Ramji S, Shankaran S, Thayyil S. Therapeutic hypothermia for neonatal encephalopathy in indian neonatal units: a survey of national practices. Indian Pediatr. 2017;54:969–70.

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  5. Sharma D, Shastri S, Sharma P. Intrauterine growth restriction: antenatal and postnatal aspects. Clin Med Insights Pediatr. 2016;10:67–83.

    PubMed  PubMed Central  Google Scholar 

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  1. Department of Neonatology, All India Institute of Medical Sciences, Jodhpur (Raj.), India

    Jogender Kumar

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Cite this article

Kumar, J. Fluid restriction in moderate and severe hypoxemic-ischemic encephalopathy: more evidence is needed. J Perinatol 39, 342–343 (2019). https://doi.org/10.1038/s41372-018-0284-7

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