Digital neonatal neurocritical care in Brazil: a retrospective multicentre cohort study of over 11,000 remotely monitored infants.

Background: Neonatal brain injury is a major global health challenge, disproportionately affecting low- and middle-income countries (LMIC), where access to specialized care remains limited. Technology-driven neuroprotective strategies may allow the dissemination of specialized care to resource-constrained settings. This study describes the implementation of a digital health strategy to deliver specialized neurocritical care to multiple neonatal intensive care units (NICUs) in Brazil. Methods: Retrospective observational multicenter cohort study analyzing data from July 2017 to June 2024, from 79 NICUs across Brazil. A digital health strategy was implemented, incorporating real-time video amplitude-integrated and raw electroencephalography (video-aEEG/EEG), near-infrared spectroscopy (NIRS), and vital signs monitoring, supported by neonatology and pediatric neurology experts available 24/7. Education and training of bedside providers were accomplished by initial in-person sessions, followed by online training. An immersive reality tool was piloted to conduct consultations between the central monitoring and bedside teams. Findings: 11,333 neonates received neurocritical care with 727,858 h of remotely recorded brain monitoring and 124,967 interactions between monitoring centers and bedside teams. Most neonates were male (57.7%), the median gestational age was 37 weeks (IQR 32-39), and the mean birth weight was 2667 g (SD ± 635 g). The most common neuromonitoring indications were suspected seizures (23.3%), moderate or severe hypoxic-ischemic encephalopathy (15.9%), and mild hypoxic-ischemic encephalopathy (13.3%). In the study population, electrographic seizures were identified in 18.4%, and a single antiseizure medication achieved seizure control in 56.1%. The first line antiseizure medication was phenobarbital (97%). Pathologic aEEG/EEG background pattern was seen in 24.9%, and sleep-wake cycling was absent in 41.2%. Simultaneous video-aEEG/EEG and NIRS monitoring data were acquired from 1688 infants. Immersive reality was successfully piloted in 2023 in a single center, enhancing consultations between central monitoring and bedside teams and standardizing the training of healthcare professionals performing the modified Sarnat exam. Interpretation: Applying digital solutions for specialized neurocritical care and training across distant and resource-limited centers is feasible and has the potential to promote equity and increase quality of care for high-risk infants. Funding: None.