Hypoxic Ischemic Encephalopathy
Hypoxic ischemic encephalopathy (HIE) is a type of brain dysfunction (brain injury) that occurs when the brain experiences a decrease in oxygen or blood flow. HIE can occur before birth, during labor and delivery or after birth. The amount of time the brain spends without oxygen or blood flow can impact how severely the brain is damaged.
Brain injury from HIE can cause developmental delay, cognitive impairment, cerebral palsy or epilepsy . The effects of HIE can become more noticeable as a baby develops. Sometimes, issues are not identified until school-age.
The full extent of damage from Hypoxic ischemic encephalopathy is typically not apparent immediately after birth, for two major reasons:
• Brain injury from HIE is an evolving process.When blood flow is cut off to parts of the brain, cells begin to break down, die, and release substances which are toxic to other cells. These cells then begin to die off and continue the chain reaction, which causes brain injury to spread over a period of hours or days. Therapeutic hypothermia can help to disrupt this chain reaction.
• Damage from HIE may occasionally not become apparent until a child has developmental delays. For example, impacts on mobility may not be noticed until the child struggles to meet milestones such as crawling or walking.
Sign & Symptoms –
Following signs and symptoms could be noticed in babies with Hypoxic ischemic encephalopathy condition –
• Decreased alertness and activity, although some babies may be more alert and react more to stimulation than a baby without HIE
• Lack of typical reflexes
• Abnormal (not typical) movements or seizures
• Low or high muscle tone
• Breathing problems
• Feeding problems
• Missing reflexes (for example, the baby does not respond to loud noises)
• Low Apgar scores
• Altered level of consciousness (e.g. not alert)
Causes –
The following health problems and negligent actions can lead to Hypoxic ischemic encephalopathy –
• Mismanagement of a high-risk pregnancy
Women with conditions such as preeclampsia and gestational diabetes require more extensive monitoring and treatment.
• Umbilical cord complications
The umbilical cord is like a lifeline between mother and baby, supplying oxygen and nutrients and removing fetal waste. Anything that compresses the cord or reduces its function puts the baby at risk of HIE.
• Placental or uterine complications
The placenta and uterus also play very important roles in providing oxygenated blood to the baby. Examples of placental and uterine issues that may cause HIE include:
• Placental abruption
when the placenta separates from the uterus before the baby is born
• Placenta previa
when the placenta attaches too close to the cervix; this can cause dangerous bleeding and oxygen deprivation during delivery
• Placental insufficiency
when the placenta is unable to deliver enough blood to the baby
• Uterine rupture
when the uterus tears, partially or completely
• Infections
Infections in the mother can spread to the baby during labor and delivery, especially if the medical team do not take adequate precautions
• Improper fetal heart monitoring
If a baby shows signs of fetal distress on the fetal heart monitor, doctors and nurses can often intervene so that their oxygen supply is restored. If necessary, this may involve an emergency C-section. However, if monitoring is sporadic or does not occur, important signs of danger may be missed.
• Failure to prevent a premature birth
Premature babies are at higher risk for HIE and other birth injuries because their lungs are so underdeveloped. Therefore, it is very important that doctors do what they can to prevent premature birth, such as performing a cervical cerclage or providing progesterone treatment.
• Allowing prolonged labor to continue
Labor is stressful for babies because uterine contractions compress the placenta and umbilical cord that supply their oxygen. If something is preventing labor from progressing, and physicians do not offer intervention (such as an emergency C-section), this is negligence. Prolonged labor is more likely to occur when a baby is larger than normal, or the mother’s pelvis is smaller than normal.
• Medication problems
Sometimes physicians prescribe medications such as Pitocin and Cytotec in order to induce or enhance labor. Unfortunately, these medications can also cause uterine contractions to become so strong and frequent that the baby is dangerously deprived of oxygen.
• Mismanagement of a neonatal condition
Hypoxic-ischemic injury can be caused by complications during the neonatal period, i.e. a baby’s first month of life. Problems such as respiratory distress, jaundice, and neonatal hypoglycemia can all contribute to an HIE diagnosis, especially if mismanaged.
Diagnosis –
A series of neuroimaging tests, including a head ultrasound (HUS) and magnetic resonance imaging (MRI) could be advised to diagnose theconditionof baby. These neuroimaging tests use machines to create pictures of the brain. The purpose of these pictures is to check for brain injury, which can lead to developmental problems in the future.
Treatment –
Hypoxic ischemic encephalopathy (HIE) is managed using a treatment called therapeutic hypothermia, where the baby’s brain or body is cooled down below normal temperatures to slow the cascade effect that causes widespread damage. This allows the baby’s brain to recover and reduces the level of disability they may have as they grow. According to current guidelines, the treatment must be given within six hours of birth, although there is some evidence to suggest it may be beneficial when given up to 24 hours.
Therapeutic hypothermia lasts for around 72 hours, allowing the baby’s metabolic rate to slow. This prevents further damage known as reperfusion injury, which occurs when normal oxygenation and blood flow are restored too quickly to the brain’s cells. While it may seem counter-intuitive that restoring flow quickly could cause further injury, the brain’s cells react differently to rapid oxygenation after being oxygen deprived. After oxygen deprivation injury, rapid oxygenation can cause more inflammation and the release of certain harmful compounds. Hypothermia treatment works to stabilize the brain’s cells and prevent or limit damaging inflammation.
In addition to therapeutic hypothermia, medical staff should provide supportive care, which can mean helping the baby breathe, controlling and preventing seizures and low blood sugar, minimizing brain swelling, and more. In the long term, babies with brain damage from HIE may benefit from a wide variety of treatments and therapies. Although these are not curative, they can minimize symptoms and maximize function.
▪︎ Other treatment & therapies
It is very important that children with HIE receive intensive early intervention in order to minimize health issues and maximize function. Exact treatment regimens will vary based on what parts of the brain were affected (and to what extent) by the oxygen deprivation. For example, a child with intellectual disabilities will require different types of intervention than one whose impairments are mainly or exclusively physical.
• Physical therapy
Physical therapy (PT) can help children develop motor skills. The goals of PT vary based on the type and severity of an individual’s disability, but may include things like learning to walk, improving strength, or increasing flexibility.
• Occupational therapy
Occupational therapy is often confused with physical therapy but focuses more on helping children complete daily tasks and develop skills to maximize their independence. Occupational therapists work with clients on fine motor skills, visual perception skills, cognitive abilities, etc.
• Speech/language pathology
Many children with HIE have speech and language disorders that impact their ability to form words, speak clearly, or process language. Speech/language pathology can help with these issues. It can also be useful for children with swallowing problems such as dysphagia.
• Behavioral and emotional therapy
Some children with HIE may have behavioral and emotional issues. Therapy may help them manage anger and other negative emotions, communicate more effectively, improve social skills, etc.
• Sensory integration therapy
Sensory Integration therapy (SIT) is meant to help children manage sensory processing issues. SIT is often classified as a complementary and alternative medicine (CAM) therapy, as, while it is highly popular, it is not yet as well-established as other forms of therapy.
• Massage therapy
Massage therapy is one treatment commonly used to help alleviate pain, relieve stress, relax tight muscles, improve circulation and digestion, and rehabilitate bodily systems. It should be used alongside other therapies.
Outcome –
The outcome of babies with HIE is variable, depending on the severity of the condition and whether a baby was treated with cooling therapy. It is important to remember that cooling therapy improves the chance of surviving HIE and living a life free from disability. Babies with HIE can live long and happy lives, but they can also experience physical and intellectual problems.
Some newborns with HIE may develop more serious impairments later in life, such as cerebral palsy, breathing problems and severe physical and intellectual disabilities.
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