Sex differences in behavioral outcome following neonatal hypoxia ischemia: Insights from a clinical meta-analysis and a rodent model of induced hypoxic ischemic brain injury

Amanda L. Smith, Michelle Alexander, Ted S. Rosenkrantz, Mona Lisa Sadek, R. Holly Fitch

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109 Scopus citations


Hypoxia ischemia (HI; reduced oxygen and/or blood flow to the brain) is one of the most common injuries among preterm infants and term infants with birth complications. Both populations show cognitive/behavioral deficits, including impairments in sensory, learning/memory, and attention domains. Clinical data suggests a sex difference in HI outcomes, with males exhibiting more severe cognitive/behavioral deficits relative to matched females. Our laboratory has also reported more severe behavioral deficits among male rats with induced HI relative to females with comparable injury (Hill et al., 2011a,b). The current study initially examined published clinical studies from the past 20. years where long-term IQ outcome scores for matched groups of male and female premature infants were reported separately (IQ being the most common outcome measure). A meta-analysis revealed a female "advantage," as indicated by significantly better scores on performance and full scale IQ (but not verbal IQ) for premature females. We then utilized a rodent model of neonatal HI injury to assess sham and postnatal day 7 (P7) HI male and female rats on a battery of behavioral tasks. Results showed expected deficits in HI male rats, but also showed task-dependent sex differences, with HI males having significantly larger deficits than HI females on some tasks but equivalent deficits on other tasks. In contrast to behavioral results, post mortem neuropathology associated with HI was comparable across sex. These findings suggest: 1) neonatal female "protection" in some behavioral domains, as indexed by superior outcome following early injury relative to males; and 2) female protection may entail sex-specific plasticity or compensation, rather than a reduction in gross neuropathology. Further exploration of the mechanisms underlying this sex effect could aid in neuroprotection efforts for at-risk neonates in general, and males in particular. Moreover, our current report of comparable anatomical damage coupled with differences in cognitive outcomes (by sex) provides a framework for future studies to examine neural mechanisms underlying sex differences in cognition and behavior in general.

Original languageEnglish (US)
Pages (from-to)54-67
Number of pages14
JournalExperimental Neurology
StatePublished - Apr 2014

Bibliographical note

Funding Information:
The authors would like to thank all the undergraduates who assisted with behavioral testing. We would also like to thank Dr. Ming-Hui Chen and Danjie Zhang of the University of Connecticut Department of Statistics for their assistance with the meta-analysis. This research was supported by NIH grant HD049792 , and internal funding from the University of Connecticut Research Foundation to RHF.


  • Hypoxia ischemia
  • Memory
  • Prematurity
  • Rapid auditory processing
  • Rodent model
  • Sex differences
  • Visual attention


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