Cerebral palsy remains an uncommon but devastating complication of preterm birth.1 There is growing evidence that early interventions can improve neurodevelopmental outcomes.2, 3 The ideal screening method to allow early initiation of interventions would be simple, low cost, available at the cot side, and provide a signal shortly after (or even prior to) birth. In this issue, Letzkus and colleagues analyzed routine heart rate (HR) recordings from neonatal intensive care from 57 infants who went on to develop cerebral palsy and 1119 who did not.4 Using highly comparative time series analysis, they found that low HR variability in the first week after birth (AUC 0.826; (0.772–0.870)) and recurrent HR accelerations at term corrected age were both associated with CP. Moreover, a combined model incorporating birthweight plus the early and late HR models was slightly better again (AUC 0.853; 0.805, 0.892).

These very encouraging findings are highly plausible given the key role of the brain stem in controlling HR variation. It would be interesting to see greater temporal granularity, particularly whether HR variation was suppressed even on very early intrapartum recordings and the early neonatal period. In preterm fetal sheep, for example, HR variation evolves dynamically over the first 72 h after acute hypoxia-ischemia.5 Severe hypoxia-ischemia is associated with initial suppression of variation, followed by a transient increase and then continuing suppression at 72 h. If certain FHRV metrics were suppressed in the early intrapartum period in at least some infants, this would be a strong indication of pre-existing injury.

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