1. Causes of neonatal mortality Lawn JE, et al. Intl J Epidemiol (2006)

2. Processes involved in HI Brain Injury 1 o energy failure ↑ Excitatory amino acids Loss of ionic balance ↑ Intracellular Ca ++ ↑ Lipases, proteases ↑ Free radicals 2 o energy failure  Activated microglia  Apoptosis  ↓ Growth factors  ↓ Protein synthesis  Oxidative injury  ↑ Excitatory amino acids

3. 0 10 20 30 40 50 60 70 80 90 100 Percent NICHD Trial: Primary Outcome Death or Disability 44% Hypothermia n = 102 RR: O.72 95% CI 0.54-0.95 P value= 0.01 62% Control Group n = 106 Shankaran S et al., N Engl J Med (2005) Shankaran S, et al. NEJM (2005) Disability defined as: Bayley MDI <70 GMFCS ≥ level 2 Hearing impairment Seizure disorder Blindness

4. Erythropoietin (Epo)  Generally used for erythropoiesis, may also provide neuroprotection  Mechanisms include: decreased apoptosis enhanced neurogenesis decreased inflammation decreased susceptibility to glutamate toxicity  Preterm infants treated with Epo for anemia have demonstrated improved neurodevelopmental outcomes Neubauer AP, et al. Ann Neurol 2010  Term infants treated with Epo have decreased seizures, improved EEG, and better neurologic outcome Zhu C, et al. Pediatrics 2009, Elmahdy H, et al. Pediatrics 2010

5. Erythropoietin improves neurologic outcome in newborns with HIE: Primary outcomes Primary outcome Death Disability Epo (N=73) 24.6 4.1 21.4 Control (n=80) 43.8 5.0 40.8 RR (95% CI) 0.62 (0.41-0.94) 0.89 (0.37-2.13) 0.59 (0.38-0.93) P value.017.999.013 Conclusion: Low dose Epo given for 2 weeks reduced the risk of disability for infants with moderate HIE without apparent side effects. Zhu C, et al. Pediatrics (2009 ) Zhu C et al. Pediatrics (2009)

6. Erythropoietin Improves neurologic outcome in HIE : Secondary outcomes Death or disability Moderate HIE Severe HIE Male Female MDI <70 Moderate HIE Severe HIE Cerebral palsy Moderate HIE Severe HIE Epo (n=73) 6.4 57.7 29.8 6.3 10.0 4.3 21.7 6.8 2.1 17.4 Control (n=80) 32.2 76.2 45.5 40.0 22.4 15.8 42.1 18.4 14.0 31.6 RR (95% CI) 0.26 (0.48-2.47) 0.70 (0.43-1.15) 0.71 (0.47-1.08) 0.18 (0.03-1.22) 0.56 (0.30-1.08) 0.38 (0.11-1.34) 0.62 (0.29-1.30) 0.51 (0.23-1.11) 0.23 (0.04-1.47) 0.67 (0.30-1.52) P value.001.227.118.029.048.106.193.051.039.468 Zhu C, et al. Pediatrics (2009 ) Zhu C et al. Pediatrics (2009)

7. NEATO: A Phase II trial  Objective: To determine if Epo administered for 7 days improves neuroradiographic and short term outcomes for moderate to severe HIE  Intervention: Epo 1000 units/kg IV or placebo at 1, 2, 3, 5 and 7 days of age  Outcome measures: MRI brain injury score and neurodevelopmental outcome at 12-14 months using Warner Initial Developmental Evaluations (WIDEA) and Alberta Infant Motor Scale (AIMS)

8. Brain MRI Injury Score OutcomeEpo (n=23)Placebo (n=25)P value Age at MRI (days)5.64.90.28 Global brain injury score None Mild Moderate Severe 35% 61% 0% 4% 12% 44% 24% 20% 0.01 Presence of brain injury by region Subcortical Cortical White matter Brainstem Cerebellar 2 or more regions 30% 17% 52% 4% 0% 30% 68% 36% 60% 16% 20% 56% 0.02 0.26 0.80 0.35 0.05 0.14 Wu Y, et al. WSPR 2016

9. Neurodevelopmental Outcomes OutcomeEpo (n=21)Placebo (n=21)P value WIDEA at 6 months Total score 75.368.80.04 WIDEA at 12 months Total score 1221100.15 Alberta Infant Motor Score (AMIS) 53.342.80.03 Moderate to severe NDI8%19%0.42 Wu Y, et al. WSPR 2016

10. NEATO Phase II trial: Results  Neonatal deaths did not differ between Epo and placebo groups (8% versus 19%, p=0.42)  Brain MRI at mean 5 days showed a lower global brain injury score in Epo treated (2 versus 11, p=0.01)  Moderate/severe brain injury, subcortical and cerebellar injury were less frequent.  At 1 year, infant motor scores were higher among Epo treated based on WIDEA (p=0.05) and AIMS (p=0.03).

11. NEATO Phase II Trial: Conclusions  High doses of Epo, in conjunction with hypothermia, resulted in less MRI brain injury and in improved short-term motor outcomes following moderate to severe hypoxic ischemic encephalopathy  A phase III trial has been designed and a grant application has been submitted to NINDS.