System allows identification of epileptic seizures in newborns

It was at the Regional Hospital of Itanhaém, where she works, located in the city of Itanhaém, in the Baixada Santista region, that nurse Ailda dos Santos Nascimento, 40, understood the importance of the hypothermia protocol and brain monitoring for high-risk newborns. First, as a healthcare professional, and in August 2020, as Nicolas's mother.​

​The delivery was difficult, the baby was born pale and did not cry. He was intubated and taken to the neonatal ICU. There, his body was cooled to 33.5°C, and electrodes were applied to his head. Brain activity monitoring allowed the identification of imperceptible epileptic seizures, and Nicolas received the appropriate medication.​

​“As a mother, I am grateful because, if it weren’t for the monitoring, we wouldn’t have noticed that my son was having a seizure. And, as a nurse, I find it important because it prevents neurological damage in children,” she says. Nicolas suffered no sequelae and is a talkative and smart boy, his mother emphasizes.​

​Cases like Nicolas's were reported in a scientific article published in the journal Jama Network Open. The text points out that in a group of 872 babies subjected to hypothermia with brain activity monitoring, 296 (33.9%) had epileptic seizures. Of these, 213 (71.9%) showed no clinical signs, such as convulsions, and were diagnosed exclusively by variations in brain waves.​

​“The greater the load of epileptic seizures, the higher the risk of permanent brain injury. If we can detect them, we treat them properly and achieve a better prognosis,” says Gabriel Variane, medical director of the Neurological Neonatal ICU at Santa Casa de São Paulo and the study's first author.​

​Santa Casa was a pioneer in performing neuroprotective hypothermia for children with perinatal asphyxia. According to the WHO (World Health Organization), lack of oxygenation before, during, or after birth is the third leading cause of neonatal death, accounting for 23% of newborn deaths, and is among the main causes of permanent brain injuries. In Brazil, the estimate is 20,000 cases of perinatal asphyxia per year.​

​The brain injury caused by asphyxia has two phases, explains Maurício Magalhães, head of neonatology at Santa Casa and co-author of the study. The first is the lack of oxygenation itself. The second usually occurs between 6 and 72 hours after resuscitation. In this phase, substances are released that kill neurons, causing permanent injuries and affecting the child's development. Reducing body temperature for 72 hours, followed by slow rewarming, decreases the dispersion of neurotoxic free radicals and, thus, the risk of death and severe neurological sequelae.​

​Asphyxia is also the main cause of epileptic seizures in the neonatal period, points out Variane. But it is not the only situation in which brain activity monitoring is indicated. The monitoring is also adopted in cases of atypical movements, central nervous system infections, malformations, and for premature babies.​

​“We published the experience of 872 babies under the hypothermia protocol, but we are very close to reaching the milestone of 10,000 monitored babies, considering all indications. Today, we hold the largest experience in newborn monitoring in the world,” says Variane.​

​This number is possible because, unlike institutions like Stanford University, a partner in the research, the system operated by the Brazilian team gathers information from various hospitals. There are currently 47, with simultaneous monitoring of dozens of newborns.​

The data is presented in real-time on panels at the headquarters of PBSF (Protecting Brains and Saving Futures), a company created by Variane to expand the availability of brain monitoring. Thanks to a partnership with Microsoft, it is also available in the cloud, allowing the 22 doctors on the team to monitor the babies from anywhere.​ ​When they observe a possibly pathological pattern in brain activity, they contact the hospital where the child is admitted and alert them to the alteration. In addition to epileptic seizures, the specialists analyze the sleep-wake cycle, associated with the baby's prognosis, and symmetry, which allows identifying brain hemorrhages.​

​If necessary, the child receives anticonvulsants, and the situation is discussed among the teams in real-time consultation. “It is a strategy that enables uniformity of care among hospitals with varying levels of resources,” emphasizes Variane.​

​For Magalhães, who was Variane’s teacher and that of almost the entire PBSF team, where he serves as scientific director, it is a lifelong project. “It started at Santa Casa de São Paulo, doing hypothermia with an ice pack, seeking partnerships. It’s exciting.”