Near-Infrared Spectroscopy Measurements of Cerebral Oxygenation in Newborns During Immediate Postnatal Adaptation
Near-Infrared Spectroscopy Measurements of Cerebral Oxygenation in Newborns During Immediate Postnatal Adaptation
L
ARTICLES
Objective In view of growing concerns regarding the optimal supplementation of oxygen at birth, we measured cerebral
oxygenation during the first minutes of life.
Study design Using near-infrared spectroscopy, changes in cerebral oxygenated hemoglobin (O 2Hb), dexoxy-genated
hemoglobin (HHb), and tissue oxygenation index (TOI) were measured during the first 15 minutes of life in 20 healthy newborn
infants delivered at term by elective cesarean section.
Results O2Hb and TOI increased rapidly within the first minutes of life (median slope for O2Hb, 3.4 mmol/Lymin; range, 1.4 to
20.6 mmol/Lymin; median slope for TOI, 4.2 %/min; range, -0.4 to 27.3%/min), and cerebral HHb decreased (median slope, -4.8
^mol/^min; range, -0.2 to -20.6 mmol/Lymin). O2Hb,TOI, and HHb all reached a plateau within 8 minutes.
Conclusions A significant increase in cerebral O2Hb and TOI and a significant decrease in HHb occur during immediate
adaptation in healthy term newborns, reaching a steady plateau at around 8 minutes after birth. (J Pediatr 2010;156:372-6).
lthough there is a substantial literature concerning the changes in peripheral arterial oxygen saturation (SpO 2) immediately afterbirth,1-3
there is much less information regarding the changes in cerebral oxygenation. This is of importance considering that worldwide, 5% to
10% of neonates require resuscitation.4,5 Over the last several decades, concerns regarding possible causes of impaired neurologic
outcome have focused on insufficient oxygenation during the perinatal period. However, based on the work of Ola Saugstad, Maximo Vento,
and other researchers, increasing attention is being given to the short- and long-term damage to newborns exposed to high oxygen
concentrations in the delivery room.6-13 The potential for injury from excessive oxygen exposure during the resuscitation of near-term or term
infants immediately after birth has been recognized only recently.14,15 Starting neonatal resuscitation in the delivery room with a lower fraction
of inspired oxygen (FiO2) has been proposed.16-18 There is a growing consensus among neonatologists regarding the need to reduce the FiO2 in
the delivery room; however, the optimal starting FiO2 value remains a matter of debate.19,20
Pulse oximetry is a noninvasive, continuous technique for monitoring SpO 2. When measured over the right hand or wirst, SpO2 is
representative of the oxygen saturation reaching the brain. Nevertheless, the changes in cerebral tissue oxygenation occurring during very early
postnatal adaptation are not fully known. Near-infrared spectroscopy (NIRS) is a well-described noninvasive technique that uses the
transparency of biological tissue to light in the near-infrared spectrum to measure cerebral tissue oxygenation.21-24 Newer near-infrared
spectrometers also can measure a quantitative tissue oxygenation index (TOI) as the ratio of cerebral oxygenated hemoglobin (O2Hb) in total
hemoglobin (O2Hb/ [O2Hb + deoxygenated hemoglobin (HHb)]). NIRS can be used to monitor cerebral hemodynamics in critically ill term and
preterm infants.21,25,26 In the present study, we measured the magnitude and timing of changes in O2Hb, HHb, TOI, and SpO2 in healthy term
newborns during the first minutes of life.
Methods
Neonates born by elective cesarean section at term were eligible for the study. The exclusion criteria were a need for neonatal resuscitation, a
genetically defined syndrome, a congenital malformation, and absence of parental consent or good-quality
NIRS signals. At our perinatal center, neo-nates
born by cesarean section are routinely
under
the
supervision of
AV
Arteriovenous
FiO2
FTOE
HHb
Deoxygenated hemoglobin
HR
Heart rate
NIRS
Near-infrared spectroscopy
O2Hb
Oxygenated hemoglobin
SpO2
THI
TOI
March 2010
Data Analysis
All continuously measured NIRS data were evaluated individually.
Fractional cerebral oxygen tissue extraction (FTOE) was calculated
as (SpO2 -TOI)/SpO2,andoxygen-arteriovenous (AV) difference
(O2-AV difference) was calculated as SpO2 - TOI. Median values and
the
25th
and
75th
percentiles were
calculated
for
O2Hb,HHb,TOI,tis-sue hemoglobin index (THI), FTOE, O2-AV
difference, HR, and SpO2 over the measurement period and shown
graphically in 1-minute intervals for the whole group. These values
were compared at 2 time periods: during the first minute of
measurement (starting point) and at 8 minutes of measurement
(plateau phase). Statistical analyses were done with the paired
Student t-test using StatView version 5.01 for Windows (SAS Inc.,
Cary, North Carolina). The slope (change in concentration per
minute) was calculated for all variables for the part of adapatation
with the largest concentration changes before the beginning of the
plateau phase.
Results
All neonates in the study were born by uncomplicated elective
cesarean section and had a normal Apgar score. No neo-
Discussion
Figure. Cerebral O2Hb, HHb, TOI, THI, FTOE, O2-AV difference, HR, and preductal SpO2 for the whole group during the first
minutes of life.
TOI values over the first 3 days of life in premature infants under 30
weeks gestation and found a significant increase in median TOI,
from 57% on day 1 to 76% on day 3. This increase was independent
of gestational age. These authors also found that although NIRS is
very sensitive to movement, TOI
ORIGINAL
ARTICLES
A better understanding of the normal adaptive changes in cerebral
oxygenation in the immediate postnatal period is useful for a more
brain-oriented neonatal medical approach that addresses concerns
about insufficient tissue oxygenation and excessive supplemental
oxygen exposure immediately after birth. Increased insight into
cerebral oxygenation will allow for expanded research in neonates
with disturbed adaptation. n
We express our gratitude to the parents for allowing us to study their
infants, as well as the midwifes and physicians involved in the management
of the neonates in the labor ward. We also thank Professor Theo Gasser and
Dr Valentin Rousson (Department ofBiostatistics, University ofZurich) for
statistical counseling. Esther Keller participated in this research project as
part ofher medical curriculum (University of Utrecht, Wilhelmina
Children's Hospital Utrecht, The Netherlands).
Submitted for publication Jan 21, 2009; last revision received Jun 16, 2009; accepted Sep
21, 2009.
Reprint requests: Jean-Claude Fauchere, MD, Neonatology Clinic, Perinatal Center,
Department of Obstetrics & Gynecology, University Hospital, Frauenklinikstrasse 10,
CH-8091 Zurich, Switzerland. E-mail: jean-claude. [email protected].
References
1. Toth B, Becker A, Seelbach-Gobel B. Oxygen saturation in healthy newborn
infants immediately after birth measured by pulse oximetry. Arch Gynecol
Obstet 2002;266:105-7.
2. Rabi Y, Yee W, Chen SY, Singhal N. Oxygen saturation trends immediately
after birth. J Pediatr 2006;148:590-4.
3. Kamlin CO, O'Donnell CP, Davis PG, Morley CJ. Oxygen saturation in
healthy infants immediately after birth. J Pediatr 2006;148:585-9.
4. Niermeyer S, Kattwinkel J, Van Reempts P, Nadkarni V, Phillips B,
Zideman D, et al. International guidelines for neonatal resuscitation: an
excerpt from the Guidelines 2000 for cardiopulmonary resuscitation and
emergency cardiovascular care of the International Consensus on Science.
Pediatrics 2000;106:e29.
5. International Liaison Committee on Resuscitation. Part 7: neonatal
resuscitation. Resuscitation 2005;67:293-303.
6. Ramji S, Ahuja S, Thirupuram S, Rootwelt T, Rooth G, Saugstad OD. Resuscitation of asphyxic newborn infants with room air or 100% oxygen.
PediatrRes 1993;34:809-12.
7. Lundstrom KE, Pryds O, Greisen G. Oxygen at birth and prolonged cerebral
vasoconstriction in preterm infants. Arch Dis Child Fetal Neonatal
Ed 1995;73:F81-6.
8. Ramji S, Rasaily R, Mishra PK, Narang A, Jayam S, Kapoor AN, et al.
Resuscitation of asphyxiated newborns with room air or 100% oxygen at
birth: a multicentric clinical trial. Indian Pediatr 2003;40:510-7.
9. Richmond S, Goldsmith JP. Refining the role of oxygen administration
during delivery room resuscitation: what are the future goals? Semin
Fetal Neonat Med 2008;13:368-74.
10. Saugstad OD, Ramji S, Soll RF, Vento M. Resuscitation of newborn infants
with 21% or 100% oxygen: an updated systematic review and
meta-analysis. Neonatology 2008;94:176-82.
11. Saugstad OD, Rootwelt T, Aalen O. Resuscitation of asphyxiated newborn
infants with room air or oxygen: an international controlled trial. The
Resair 2 Study. Pediatrics 1998;102:e1.
12. Sola A, Saldeno YP, Favareto V. Clinical practices in neonatal oxygenation: where have we failed? What can we do? J Perinatol 2008;28:S28-34.
13. Vento M, Asensi M, Sastre J, Garcia-Sala F, Pallardo FV, Vina J. Resuscitation with room air instead of 100% oxygen prevents oxidative stress in
moderately asphyxiated term neonates. Pediatrics 2001;107:642-7.
Near-Infrared Spectroscopy Measurements of Cerebral Oxygenation in Newborns during Immediate Postnatal Adaptation
5
375
Fauchere et al
15. Vento M, Sastre J, Asensi MA, Vina J. Room-air resuscitation causes less
damage to heart and kidney than 100% oxygen. Am J Resp Crit Care
Med 2005;172:1393-8.
16. Canadian Paediatric Society. Amendment to the NRP instructor's manual
(Canadian Adaptation of NRP 2006. Neonatal Resuscitation Textbook, 5
th edition AAP/AHA 2006) 2006. Available at http://www.cps.
ogy 2008;94:237-44.
25. Bernert G, von Siebenthal K, Kohlhauser C, Casaer P. Near-infrared
spectroscopy: methodological principles and clinical application in
pre-term infants. Wien Klin Wochenschr 1995;107:569-73.
26. Adcock LM, Wafelman LS, Hegemier S, Moise AA, Speer ME, Contant
CF, et al. Neonatal intensive care applications of near-infrared
spectroscopy. Clin Perinatol 1999;26:893-903.
27. Peebles DM, Edwards AD, Wyatt JS, Cope M, Delpy DT, Reynold EO.
Changes in human fetal cerebral oxygenation and blood volume during
delivery. Am J Obstet Gynecol 1992;167:1916-7.
28. Isobe K, Kusaka T, Fujikawa Y, Kondo M, Kawada K, Yasuda S, et al.
Changes in cerebral hemoglobin concentration and oxygen saturation
immediately after birth in the human neonate using full-spectrum
near-infrared spectroscopy. J Biomed Opt 2000;5:283-6.
29. Naulaers G, Morren G, Van Huffel S, Casaer P, Devlieger H. Cerebral tissue oxygenation index in very premature infants. Arch Dis Child Fetal
Neonatal Ed 2002;87:F189-92.
30. Pryds O, Greisen G. Effect ofPaCO2 and haemoglobin concentration on
day-to-day variation of CBF in preterm neonates. Acta Paediatr Scand
Suppl 1989;360:33-6.
31. Pellicer A, Valverde E, Gaya F, Quero J, Cabanas F. Postnatal adaptation
of brain circulation in preterm infants. Pediatr Neurol 2001;24:
103-9.
32. Mariani G, Dik PB, Ezquer A, Aguirre A, Esteban ML, Perez C, et al.
Pre-ductal and postductal O2 saturation in healthy term neonates after
birth. J Pediatr 2007;150:418-21.
33. Saugstad OD. Oxygen saturations immediately after birth. J Pediatr
2006;148:569-70.