Journal of Perinatology (2017) 00, 1–6

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ORIGINAL ARTICLE
Erythropoietin monotherapy in perinatal asphyxia with
moderate to severe encephalopathy: a randomized
placebo-controlled trial
RR Malla1, R Asimi2, MA Teli1, F Shaheen3 and MA Bhat1

OBJECTIVE: Erythropoietin (EPO) is neuroprotective after asphyxia in animal studies. The efficacy and safety of EPO monotherapy in
term neonates with hypoxic ischemic encephalopathy (HIE) is uncertain.
STUDY DESIGN: Hundred term neonates with moderate or severe HIE were randomized by random permuted block algorithm to
receive either EPO 500 U kg− 1 per dose in 2 ml saline intravenously (50 neonates) on alternate days for a total of five doses with the
first dose given by 6 h of age (treatment group) or 2 ml of normal saline (50 neonates) similarly for a total of five doses (placebo
group) in a double-blind study. No hypothermia was given. The primary outcome was combined end point of death or moderate or
severe disability at mean age of 19 months (s.d., 0.61).
RESULTS: Death or moderate or severe disability occurred in 40% of neonates in the treatment group vs 70% in the placebo group
(risk ratio, 0.57; 95% confidence interval (CI) 0.38 to 0.85; P = 0.003). Death occurred in 16% of patients in both the groups (risk ratio,
1.0; 95% CI 0.33 to 2.9; P = 0.61). The risk of cerebral palsy was lower among survivors in the treatment group (risk ratio, 0.52; 95% CI
0.25 to 1.03; P = 0.04) and lesser number of babies were on anticonvulsants at assessment (risk ratio, 0.47; 95% CI 0.20 to 1.01;
P = 0.03). Neonatal brain magnetic resonance imaging showed more abnormalities in the placebo group (relative risk, 0.66; 95% CI
0.42 to 1.03; P = 0.04)). Improvement in other neurological outcomes was not significant.
CONCLUSION: EPO monotherapy reduces the risk of death or disability in term neonates with moderate or severe encephalopathy.
Journal of Perinatology advance online publication, 9 March 2017; doi:10.1038/jp.2017.17

INTRODUCTION encouraging.17,18 These studies suggest that EPO may be used

Hypoxic ischemic encephalopathy (HIE) is associated with signifi-
cant morbidity and mortality during neonatal period and neurode-
velopmental disability in the long term. Patients with moderate HIE
have a 10% risk of death and 30% risk of disability among survivors.
Among patients with severe HIE, 60% patients die and almost all
survivors develop disability.1–3 Therapeutic hypothermia when
initiated within first 6 h of birth has been shown to improve the
immediate as well as long-term outcome in HIE.4–7 However clinical
trials suggest that around 24 to 38% of infants who receive
hypothermia die and another 35 to 41% of patients develop
developmental disability at 18 to 22 months of age.4,8 Also
hypothermia is most beneficial to babies with moderate encepha-
lopathy and meta-analysis show minor benefit to babies with
severe HIE.6 So there is need for other modalities that could also
have neuroprotective as well as neurorestorative properties.
Recombinant human erythropoietin (EPO) has been extensively
studied as a neuroprotective agent in animal models. EPO and
erythropoietin receptor are expressed by various cells in the brain
that include neuronal progenitor cells, subsets of mature neurons,
oligodendrocytes, astrocytes and microglia.9–14 Hypoxic ischemia
of the brain leads to increased expression of EPO and
erythropoietin receptor in neurons mediated by hypoxia inducible
factor, which is an endogenous neuroprotective mechanism.15,16
Few studies have evaluated the neuroprotective role of EPO in
term neonates with perinatal asphyxia and the results were
with hypothermia for neuroprotection or may be used as an
acceptable alternative in resource poor settings where standard
cooling machines are not available. As 23% of neonatal deaths
occur as a consequence or related to HIE and most of these occur
in regions where cooling is not available, early treatment with EPO
may provide a much needed approach to improve outcomes.
Although most studies of additional neuroprotective therapies for
HIE focus on testing an adjuvant therapy to be given in
conjunction with hypothermia, this study is asking whether a
different therapy altogether is effective, that can be used in low-
resource settings where hypothermia is unavailable or not
available for all babies.
MATERIALS AND METHODS
This was a prospective longitudinal study conducted in the neonatal
intensive care unit of the Sheri Kashmir Institute of Medical Sciences
(SKIMS), Srinagar, Kashmir, which is a tertiary-care hospital in northern
India from December 2012 to November 2015. The infants enrolled in the
study were born in the obstetric department of SKIMS, Jhelum Valley
Medical College and Lalded hospital. The total number of babies born in
the obstetric unit of SKIMS and Jhelum Valley Medical College is 10 000 per
year, whereas at Lalded hospital it is 22 000 per year. All infants were
enrolled after parental consent (written and verbal format) and the study
was approved by the Institutional Ethics Committee (IEC).
All neonates who were ⩾ 37 weeks of gestation, o6 h of age and had
evidence of moderate or severe HIE were eligible for inclusion in the study.

1
Department of Paediatrics, Sheri Kashmir Institute of Medical Sciences, Srinagar, India; 2Department of Neurology, Sheri Kashmir Institute of Medical Sciences, Srinagar, India and
3
Department of Radiodiagnosis and Imaging, Sheri Kashmir Institute of Medical Sciences, Srinagar, India. Correspondence: Professor MA Bhat, Department of Paediatrics, Sheri
Kashmir Institute of Medical Sciences, Srinagar 190011, India.
Email: mbhat47@rediffmail.com
Received 26 July 2016; revised 7 January 2017; accepted 17 January 2017
 Erythropoietin neuroprotection in perinatal asphyxia
RR Malla et al
2
Perinatal asphyxia was defined as 10 min Apgar score o 5 together with
evidence of two of the following three criteria and evidence of moderate
or severe neonatal encephalopathy.
1. History of fetal distress (late deceleration or loss of beat-to-beat
variability or fetal bradycardia or meconium-stained amniotic fluid).
2. Need for immediate neonatal ventilation with a bag and mask or
through endotracheal intubation for ⩾ 10 min after delivery.
3. Base deficit of ⩾ 16 mEq l − 1 and/or pH 7.0 or less in cord blood or
admission arterial blood samples taken within the first hour after birth.
Moderate or severe neonatal encephalopathy in these neonates was
diagnosed by certified examiners when one sign was present in 43 of the
following six categories:19
(1) Level of consciousness: lethargy (moderate HIE) or stupor or coma
(severe HIE).
(2) Spontaneous activity: decreased (moderate HIE) or absent (severe HIE).
(3) Tone: hypotonia (moderate HIE) or flaccidity (severe HIE).
(4) Posture: distal flexion (moderate HIE) or decerebrate state (severe HIE).
(5) Primitive reflexes: suck weak (moderate HIE) or absent (severe HIE) or
moro reflex incomplete (moderate HIE) or absent (severe HIE).
(6) Autonomic nervous system: pupils constricted (moderate HIE) or
deviated, dilated or non-reactive to light (severe HIE), bradycardia
(moderate HIE) or variable heart rate (severe HIE), or periodic breathing
(moderate HIE) or apnea (severe HIE).
On duty neonatologists (six senior residents with post graduation in
pediatrics ) acted as certified examiners and were certified when there was
concordance in three of the examinations with that of the lead instructors
regarding the stage of HIE.
Babies with congenital anomalies, chromosomal abnormalities, con-
genital infections, severe intrauterine growth retardation (o2 s.d. below
the mean) and inborn errors of metabolism were excluded from our study.
The patients were randomized into treatment and placebo group, and
randomization was done by random permuted block algorithm with block
size of two and four. Treatment group received recombinant human EPO
within 6 h after birth at a dose of 500 U kg − 1 intravenously on alternate
days for a total of five doses. It was diluted in 2 ml of normal saline and
administered intravenously over a period of 1 min. Placebo group received
2 ml of normal saline on the same schedule. The investigators, caregivers
and families were blinded to the assignment of patients (double blind).
All the infants were nursed on servo-controlled open care beds, with
skin temperature maintained at 36.5°C. No hypothermia was given.
Electroencephalography monitoring was done at admission and subse-
quently at 10 to 14 days of life depending upon the condition of the baby.
All electroencephalography's were reported by neurologists blinded to the
assignment of patients.
During the initial 72 h of life, heart rate, respiratory rate, blood pressure
and oxygen saturation was monitored continuously. HIE scoring was done
at admission and every 12 h during the initial 7 days and subsequently on
day 10 and day 14 according to the Thompson’s HIE score.20 Mean HIE
score for each baby was calculated daily by taking an average of all scores
every 24 h. Arterial blood gases, electrolyte measurements, hemogram,
renal function tests and liver function tests were performed daily for the
first 5 days or earlier depending upon the condition of the baby.
Hemogram was repeated on day 10, 1 and 3 months of life. All neonates
were subjected to magnetic resonance imaging (MRI) between tenth and
fourteenth day of life or as permitted by the condition of the baby. All
MRI's were reported by neuroradiologist blinded to the assignment of
patients.
Outcome
The primary outcome was death or moderate or severe disability at mean
age of 19 months (s.d., 0.61). Data regarding growth, brainstem auditory-
evoked response, vision were obtained. Neuromotor disability was based
on the presence of cerebral palsy and functional disability on the basis of
Gross Motor Function Classification (GMFCS) system where level 1 includes
children who walk independently with some gait abnormalities; level 2
includes those who are unable to walk but who can sit, pull to standing
and cruise; level 3 includes those who are unable to walk or crawl, use
hands for sitting support; level 4 includes those for whom support is
needed for sitting; and level 5 includes those who require adult assistance
Journal of Perinatology (2017), 1 – 6
to move.21 Developmental examination was done by Bayley Scale of Infant
Development II on which the standardization mean (± s.d.) is 100 ±15.22
Severe disability was defined as GMFCS grade of level 3 to 5, hearing
impairment requiring hearing aids, bilateral cortical visual impairment with
no useful vision or Bayley Mental Development Index Score o70.
Moderate disability was defined as Bayley Mental Developmental Index
Score between 70 and 84 and any one of the following criteria: GMFCS
grade of level 2, hearing impairment with no amplification or persistent
seizure disorder.
Adverse outcomes included intracranial hemorrhage, pulmonary
hemorrhage, pulmonary hypertension, persistent hypotension, prolonged
coagulation time, culture-proven sepsis, necrotizing enterocolitis, throm-
bocytopenia, major venous thrombosis, renal failure needing dialysis,
pulmonary air leaks, duration of hospitalization.
Secondary outcomes at 19 months included disability, Bayley Mental
and Psychomotor Developmental Index (mean score 100 ± 15), cerebral
palsy, cortical visual impairment, hearing loss, seizures needing
anticonvulsants.
Statistical analysis
Sample size of 50 infants in each group was based on a two-tailed type 1
error rate of 0.05%, a statistical power of 80 and 10% loss to the follow-up
and an incidence of death or disability in the control group of 70% and a
reduction by 50% in the intervention group. The data were analyzed by
Fisher’s exact tests for the categorical variables and with t-tests for the
continuous variables. The data for the primary and secondary outcomes
were analyzed by the Mantel–Haenszel test.
RESULTS
From December 2012 to November 2015, 293 neonates with
diagnosis of HIE were screened. Out of these, 163 did not meet the
inclusion criteria (no moderate or severe encephalopathy) and 20
patients met criteria for exclusion. Of the remaining 110 patients,
10 patients were excluded because parents refused to participate
(Box1). Remaining 100 patients (50 in the treatment group and 50
in the placebo group) were enrolled into the study. Baseline
characteristics of the infants were broadly similar between the two
groups (Table 1).
Adverse outcomes
The incidence of adverse outcomes was similar between the two
groups (Table 2). Hypotension, hepatic dysfunction, prolonged
coagulation and necrotizing enterocolitis were similar between
the two groups. Although red blood cell indices (hemoglobin, red
blood cell count and reticulocyte count) were elevated in the
treatment group on day 10 of life, these normalized by 1 month of
age and no complications were seen. There were no patients with
hypertension, polycythemia or thrombosis secondary to EPO.
Primary outcome at 19 months
In the treatment group, 8 patients died (6 in the neonatal period
and 2 during follow-up) and 12 patients survived with severe or
moderate disability, whereas in the placebo group 8 patients died
(6 in the neonatal period and 2 during follow-up) and 27 patients
survived with severe or moderate disability (Table 3; relative risk,
0.57; 95% confidence interval (CI), 0.38 to 0.85; number needed to
treat 4).
Secondary outcome at 19 months
Outcome was significantly better in the treatment group in many
of the secondary outcome parameters (Table 3).There was less risk
of death or disability among patients with moderate encephalo-
pathy in the treatment group (relative risk, 0.33; 95% CI 0.12 to
0.79; P = 0.004). Survival without neurological abnormality was
significantly increased in the treatment group (71%) than in the
placebo group (30%) (relative risk, 0.65; 95% CI 0.45 to 0.94;
P = 0.016). Patients in the treatment group had lower risk of
© 2017 Nature America, Inc., part of Springer Nature.

cerebral palsy (relative risk, 0.52; 95% CI 0.25 to 1.03; P = 0.04) than
patients in the placebo group. Also lesser number of babies were
on anticonvulsants at assessment in the treatment group (risk
Table 1. Baseline characteristics of the infants
Erythropoietin neuroprotection in perinatal asphyxia
RR Malla et al
3
ratio, 0.47; 95% CI 0.20 to 1.01; P = 0.03). There was no effect on
rest of the parameters between the two groups.
On subgroup analysis more patients with severe encephalo-
pathy (34/50, 68%) died or had disability than those with
moderate encephalopathy (21/50, 42%) (relative risk, 0.55; 95%
CI 0.33 to 0.90; P = 0.009)

Variable Treatment Placebo group P-value Neonatal outcomes

group During neonatal period, 12% patients died in each group.
Abnormal electroencephalography at discharge was seen in 33%
(n = 50) (n = 50) ( o0.05 sig.) of patients in the treatment group vs 66% of patients in the
placebo group (relative risk, 0.81; 95% CI 0.51 to 0.32; P = 0.001).
Males 28 (56%) 31 (62%) 0.46 Abnormalities on MRI were seen more in the placebo group
Birth weight (grams) 2902 ± 444 3136 ± 660 0.9
(Table 2; relative risk, 0.66; 95% CI 0.42 to 1.03; P = 0.04). The
(mean ± s.d.)
Gestational age (weeks) 39.4 ± 1.23 39.7 ± 0.78 0.30 abnormalities included injury to the subcortical areas (posterior
Mode of delivery limb of internal capsule, thalamus, basal ganglia), cortical injuries
Vaginal 12 (24%) 16 (32%) 0.36 and cerebellar injuries.
Emergency cesarean 38 (76%) 34 (68%)

Meconium-stained 32 (64%) 22 (54.2%) 0.44 DISCUSSION

liquor Our study shows that treatment with EPO caused a significant
Apgar score 4.9 ± 1.3 4.7 ± 0.8 0.43 reduction in the risk of primary outcome, the combined rates of
(mean ± s.d.) (10 min)
Resuscitation required at 46 (92%) 45 (90%) 0.9 death or moderate or severe encephalopathy.
10 min The immediate neuroprotective effects of EPO include
Blood gases (cord blood or within first hour after birth) decreased nitric oxide production, activation of antioxidant
pH (mean ± s.d.) 7.00 ± 0.13 7.0 ± 0.11 0.26 enzymes, reduction of glutamate toxicity, inhibition of lipid
BE (mean ± s.d.) 18.9 ± 4.3 17.7 ± 4.0 0.21 peroxidation and reduction of inflammation, whereas the long-
term neuroprotective effects include generation of neuronal anti-
Mean HIE score (± s.d.) 12.5 ±2.9 12.5 ± 3.5 0.14 apoptotic mechanisms, stimulation of angiogenesis and modula-
Age at first dose 1.12 (1.5– 1.5 (2–3.5) 0.5
(interquartile range, 2.62)
tion of neurogenesis.23
25th–75th percentile) Under normal circumstances only 1 to 2% of circulating EPO
Mean arterial blood 45.3 ± 5.0 45.5 ± 4.6 0.861 crosses blood–brain barrier mainly by passive diffusion.24,25
pressure at admission However in the setting of hypoxic ischemia, there is an increased
(mean ± s.d.) permeability of the blood–brain barrier and doses of 300 to 500
Stage of HIE U kg − 1 are associated with a significant rise in cerebrospinal fluid
Moderate 24 (48%) 26 (52%) 0.65 EPO levels.26,27 Zhu et al.17 in their study of 83 infants (30 received
Severe 26 (52%) 24 (48%) 0.65
EPO at a dosage of 500 IU kg −1 per day and the rest at a dosage of
Abbreviations: BE, Base excess; HIE, hypoxic ischemic encephalopathy. 300 IU kg − 1 per day) reported EPO to be safe in all the treated
infants. High doses of EPO given subcutaneously in neonatal rat

Table 2. Status during the hospital stay and at discharge

Variable Treatment group Placebo group Relative risk P-value

N = 50(%) N = 50(%) (95% CI)

Oliguria 21 (42%) 30 (60%) 0.70 (0.45–1.07) 0.07

Renal failure 20 (40%) 28 (56%) 0.71 (0.45–1.12) 0.17
Hypotension requiring vasopressors 30 (60%) 33 (66%) 0.90 (0.65–1.26) 0.10
Hepatic dysfunction 18 (36%) 21 (42%) 0.85 (0.49–1.4) 0.54
Necrotizing enterocolitis 1 (2%) 4 (8%) 0.25 (0.01–2.27) 0.16
Disseminated intravascular coagulation 15 (30%) 18 (36%) 0.83 (0.44–1.54) 0.78
Ventilated 18 (36%) 17 (34%) 1.05 (0.58–1.91) 0.83
Death (neonatal period) 6 (12%) 6 (12%) 1.0 (0.33–2.9) 1.0
Day of initiation of oral feeds (mean ± s.d.) 6.0 ± 4.3 9.7 ± 5.1 0.006
Full oral feeds (mean ± s.d. days) 7.4 ± 4.8 11.3 ± 5.3 0.008
Mean duration of hospital stay (mean ± s.d.) 9.7 ± 6.9 13.5 ± 8.1 0.04
Hemoglobin on day 10 (± s.d.) 17.4 ±1.9 15.7 ± 2.2 0.004
Red blood cell count on day 10 (± s.d.) 5.2 ±0.45 5.2 ± 0.45 0.014
Reticulocyte count on day 10 (± s.d.) 4.1 ±0.5 3.2 ± 0.5 0.001
MRI abnormalities 20 (40%) 30 (60%) 0.66 (0.42–1.03) 0.04
Status at discharge
Gavage feeding 5 (10%) 6 (12%) 0.83 (0.23–2.9) 0.75
Abnormal EEG 17 (34%) 33 (66%) 0.81 (0.51–0.32) 0.001
Seizures requiring treatment 13 (26%) 28 (57%) 0.46 (0.25–0.80) 0.002
Abbreviations: CI, confidence interval; EEG, electroencephalography; MRI, magnetic resonance imaging.

© 2017 Nature America, Inc., part of Springer Nature. Journal of Perinatology (2017), 1 – 6
 Erythropoietin neuroprotection in perinatal asphyxia
RR Malla et al
4
Table 3. Outcome at 19 months of age

Variable Treatment group Placebo group Relative risk P-value (95% CI)

Primary outcome
Death or moderate or severe disability 20/50 (40%) 35/50 (70%) 0.57 (0.38–0.85) 0.003

Secondary outcome
Death 8/50 (16%) 8/50 (16%) 1 (0.33–2.9) 0.61
Death or disability
Among patients with moderate encephalopathy 5/24 (21%) 16/26 (61%) 0.33 (0.12–0.79) 0.004
Among patients with severe encephalopathy 15/26 (57%) 19/24 (79%) 0.72 (0.51–1.3) 0.10
Neurodevelopmental abnormalities 12/42 (29%) 27/42 (64%) 0.44 (0.25–0.76) 0.001
Survival without neurological abnormalities 30/42 (71%) 15/42 (35%) 0.65 (0.45–0.94) 0.01
Cerebral palsy 10/42 (23%) 19/42 (45%) 0.52 (0.25–1.03) 0.04
Hearing impairment 2/42 (4.7%) 2/42 (4.7%) 1 (0.33–2.9) 1.0
Seizures requiring anticonvulsants at the time of assessment 8/42 (19%) 17/42 (43%) 0.47 (0.20–1.01) 0.03

Bayley Mental Development Index Score

o70 8/40 (20%) 15/40 (37%) 0.53 (0.22–1.18) 0.08
70–84 5/40 (12%) 6/40 (15%) 0.83 (0.23–2.90) 0.74
485 27/40 (67%) 19/40 (47%) 0.62 (0.34–1.10) 0.07

Bayley Psychomotor Development Index Score

o70 9/40 (23%) 15/40 (37%) 0.60 (0.26–1.28) 0.14
70–84 4/40 (10%) 5/40 (13%) 0.80 (0.18–3.2) 0.72
485 27/40 (67%) 20/40 (50%) 0.65 (0.35–1.17) 0.11
Abbreviation: CI, confidence interval. For Bayley scale of infant development testing, data for two patients in both the groups were not available.

models (2500 and 5000 units) have been found to be safe and
improved the development of hypoxia-exposed newborn rats and
prevented learning impairment and dopamine neuron loss in
these rats.27 Wu et al.28 have reported EPO dose of 1000 U kg − 1 to
produce plasma levels in neonates that are neuroprotective in
animals. However we used 500U kg − 1 of EPO keeping in view the
safety profile seen with studies by Zhu et al. and the side effects
seen in adults with high doses of EPO.
There was reduced risk of death or disability in the treatment
group than in the placebo group in our study (relative risk, 0.57;
95% CI 0.38 to 0.85; P = 0.003). Zhu et al.17 in their study also
reported reduced risk of death or disability in the EPO group than
in the control group (relative risk 0.62; 95% CI 0.41 to 0.94;
P = 0.017). Death or disability rate in the placebo group in our
study was 70% vs 43.8% in the study by Zhu et al. This was
because of lesser number of patients with severe HIE in the study
by Zhu et al. than in our study (26% vs 50%). However the death
or disability rate of 70% in the placebo group in our study is
similar to the death or disability rate of 66.6% reported by the
other studies.4,8
There was an improvement in survival without neurological
abnormality (relative risk 0.65; 95% CI 0.45 to 0.94; P = 0.01) in the
treatment group in our study. Also the risk of developing cerebral
palsy was less in the treatment group (relative risk, 0.52; 95% CI
0.25 to 1.03; P = 0.04). Various animal studies have explored the
mechanism through which EPO exerts its neuroprotective effect.
In their study of neonatal rats with focal cerebral ischemia, Chang
et al.29 noted markedly preserved hemispheric volume in the EPO-
treated group. During the acute post-injury period, EPO had anti
inflammatory and anti-apoptotic roles, and during recovery it has
neurogenic and vasculogenic effects.30,31 In human adults with
stroke, EPO was shown to reduce infarction size slightly and to
improve clinical outcomes slightly.32
EPO has also shown promising results when combined with
hypothermia for HIE. Follow-up of 22 infants enrolled in a phase I
clinical trial of EPO-augmented hypothermia (no comparison
group) for treatment of neonatal encephalopathy found no deaths
and only one infant with moderate–severe disability at age 2
years.33 A study of 45 term infants comparing single-dose EPO
alone on day 0 with 72 h therapeutic hypothermia alone for
treatment of NE found superior protection in the hypothermia
group.34 In a recent study of high-dose EPO and hypothermia for
HIE, Wu et al.35 demonstrated reduced severity of brain injury on
neonatal MRI and improved short-term motor outcomes in those
patients who received EPO as an adjunctive therapy to
hypothermia. Neonatal MRI in our study showed more normal
brain MRI in the treatment group than in the placebo group
consistent with above results.
We could not demonstrate a beneficial effect of EPO in patients
with severe encephalopathy as death or disability was more in
these neonates (relative risk, 0.55; 95% CI 0.33 to 0.90; P = 0.009).
This could be because of the severity of the initial insult or
because of inadequate neuroprotection with our dose of EPO as
Wu et al.28 have demonstrated EPO dose of 1000 U kg − 1 to
produce plasma levels in neonates that are neuroprotective in
animals.
Expect for mild increase in hemoglobin and mean red blood cell
volume (which normalized in the neonatal period), no side effects
of EPO were documented in our patients. Studies of neuropro-
tective role of EPO in term and preterm neonates performed to
study appropriate dosing, effectiveness and safety have also not
seen any side effects like polycythemia, thrombosis and hyperten-
sion as are seen in adults28,36
The strength of our study is that this is the first study where a
consistent dose of 500 U kg − 1 of EPO was given to the neonates
in the treatment group within 6 h of life. Also MRI and
electroencephalography were done in all the patients in the
neonatal period. Follow-up was good and no patient was lost
during the follow-up. However there are many limitations. We
could study only 100 patients over a period of 2 years being a
single-center study. Better sample size as used in various
hypothermia trials would have been more beneficial. Also lower
dose of EPO could be one of the reasons for not demonstrating
beneficial effect in neonates with severe encephalopathy. As only
severe disabilities will be picked up by 19 months of age and
minor impairments might go unrecognized, evaluation at 6 to 7

Journal of Perinatology (2017), 1 – 6 © 2017 Nature America, Inc., part of Springer Nature.

Box 1 Method of enrollment of study patients
Assessed for eligibility
N = 293
Not meeting inclusion criteria (n = 163)
(no moderate or severe encephalopathy)
Exclusion criteria (n = 20)
Refused to participate
(n = 10)
Randomized
(n = 100)
Allocated to intervention: Allocated to intervention
(Erythropoietin): (Placebo)
(n = 50): (n = 50)
Received allocated intervention: Received allocated intervention
(n = 50): (n = 50)
Lost to follow-up: Lost to follow-up
(n = 0): (n = 0)
Final analysis: Final analysis
(n = 50): (n = 50)
years of age is needed to assess for improvement in other
parameters.
In conclusion, our study confirms that treatment with EPO
during the first 6 h of life in neonates with moderate to severe
encephalopathy improves the combined outcome of death or
moderate or severe disability at 19 months of age. In settings
where hypothermia is unavailable or not available for all babies,
EPO may be a much needed neuroprotective therapy as it has a
low number needed to treat and is relatively easy to administer. At
centers where hypothermia is available, it is used as an add on
therapy due to its neuroprotective properties. However more
multicentric trials are needed to corroborate the results.
What is known about topic
● The efficacy and safety of erythropoietin in term neonates with
perinatal asphyxia is uncertain.
What this study adds
● Erythropoietin reduces the risk of death or disability in term
neonates with perinatal asphyxia with moderate to severe disability.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
ACKNOWLEDGEMENTS
We, Dr Rahid and Dr Mushtaq, had full access to all of the data in the study and take
responsibility for the integrity of the data and the accuracy of the data analysis.
AUTHOR CONTRIBUTIONS
Dr Mushtaq conceptualized and designed the study, drafted the initial
manuscript and approved the final manuscript as submitted. Drs Rahid, Rouf
and Manzoor carried out the initial analyses, reviewed and revised the
manuscript, and approved the final manuscript as submitted. Dr Feroz
coordinated and supervised data collection, critically reviewed the manuscript
and approved the final manuscript as submitted.
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