eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Hypoxic-Ischemic Encephalopathy: Follow-up

Author: Santina A Zanelli, MD, Assistant Professor, Department of Pediatrics, Division of Neonatology, University of Virginia Health System
Coauthor(s): Dirk P Stanley, MD, Resident Physician, Department of Pathology, University of Virginia Health System; David Kaufman, MD, ECMO Director, Associate Professor of Pediatrics, Department of Pediatrics, Division of Neonatology, University of Virginia Health System
Contributor Information and Disclosures

Updated: Dec 15, 2008

Follow-up

Further Inpatient Care

  • Close physical therapy and developmental evaluation are needed before discharge in patients with hypoxic-ischemic encephalopathy (HIE).

Further Outpatient Care

  • As noted above, most infants do not need specific outpatient care. However, they should be monitored in a regular pediatric clinic. Severely disabled children may need to be monitored in multispecialty clinics and by a developmental neurologist.
  • Infants that have undergone hypothermia therapy should be followed by a developmental specialist, as an ongoing assessment of this newly introduced therapy. Data should be entered into available registry, database, or both whenever possible. 

Inpatient & Outpatient Medications

  • Continuation of seizure medications should depend on evolving CNS symptoms and EEG findings.
  • In most infants who are developing normally and have a normal EEG before hospital discharge, phenobarbital is discontinued within 3-4 weeks of birth.
  • In those with significant CNS disability with or without persistent episodes of seizures, phenobarbital is continued for 3-6 months; the decision to wean off the drug depends on later changes in EEG and clinical course.

Transfer

  • Infants who present in a level I or II center may require transfer to a tertiary neonatal ICU for definitive neurodiagnostic studies (EEG and neuroimaging), consultation with a pediatric neurologist, and evaluation for hypothermia therapy.

Deterrence/Prevention

Most treatments discussed below are experimental. With the exception of hypothermia (still under investigation) none has consistently shown efficacy in human infants.

  • Allopurinol: Slight improvements in survival and cerebral blood flow (CBF) were noted in a small group of infants tested with this free-radical scavenger in one clinical trial.16
  • High-dose phenobarbital: In another study, 40 mg/kg phenobarbital was given over 1 hour to infants with severe hypoxic-ischemic encephalopathy.17 Treated infants had fewer seizures (9 of 15) than untreated control infants (14 of 16). Treated infants also had fewer neurological deficits at age 3 years (4 of 15) than untreated infants (13 of 16). No other trials confirming these findings have been reported.
  • Excitatory amino acid (EAA) antagonists: MK-801, an EAA antagonist, has shown promising results in experimental animals and in a limited number of adult trials. This drug has serious cardiovascular adverse effects.

Complications

Prognosis

  • See Mortality/Morbidity for data on outcomes.
  • Accurate prediction of the severity of long-term complications is difficult, although the following pointers may be used:
    • Lack of spontaneous respiratory effort within 20-30 minutes of birth almost always associated with death.
    • The presence of seizures is an ominous sign. The risk of poor neurological outcome is distinctly greater in such infants, particularly if seizures occur frequently and are difficult to control.
    • Abnormal clinical neurological findings persisting beyond the first 7-10 days of life usually indicate poor prognosis. Among these, abnormalities of muscle tone and posture (hypotonia, rigidity, weakness) should be carefully noted.
    • An EEG done at about 7 days that has normal background activity is a good prognostic sign.
    • Persistent feeding difficulties, which generally are due to abnormal tone of the muscles of sucking and swallowing, also suggest significant CNS damage.
    • Poor head growth during the postnatal period and the first year of life is a sensitive finding predicting higher frequency of neurologic deficits.

Miscellaneous

Medicolegal Pitfalls

  • Birth asphyxia, birth injury, and perinatal asphyxia are terms often used incorrectly to describe hypoxic-ischemic encephalopathy (HIE).
    • Birth injury is a condition in which fetal or neonatal injury has occurred during the process of birth (ie, during the first and second stages of labor). Examples include brachial plexus injury; fracture of the clavicle; forceps-induced damage to the facial nerve or soft tissues; and cuts or bruises from scissors, clips, or scalp monitors.
    • Birth asphyxia is similar to birth injury in that asphyxia occurs during the first and second stages of labor when the fetus was otherwise normal.
    • Perinatal asphyxia signifies that asphyxia occurred at any time in the perinatal period, namely, from conception through the first month of life.
  • The AAP and ACOG recommend using hypoxic-ischemic encephalopathy because this term accurately describes the clinical condition, encephalopathy from asphyxia, without implying the time of brain injury. The AAP and ACOG also advise not using the terms perinatal asphyxia or birth asphyxia because it is difficult to identify the time of brain injury and nearly impossible to ascertain that the brain had been "normal" before such injury.
  • All professional societies encourage accurate recording of objective information in the medical records, including maternal and neonatal history and the clinical and laboratory findings.
  • The findings from brain imaging procedures and EEG help in the total assessment of the infant's clinical status.
  • No diagnostic tests conclusively prove that a given magnitude of asphyxia has led to a specific neurological injury. Acute perinatal and intrapartum events have been found in only about 20% of children diagnosed as having cerebral palsy.
  • Counseling the parents with realistic explanations about their infant's clinical status and prognosis is always recommended.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Tonse NK Raju, MD, to the development and writing of this article.



More on Hypoxic-Ischemic Encephalopathy

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Differential Diagnoses & Workup: Hypoxic-Ischemic Encephalopathy
Treatment & Medication: Hypoxic-Ischemic Encephalopathy
Follow-up: Hypoxic-Ischemic Encephalopathy
Multimedia: Hypoxic-Ischemic Encephalopathy
References
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Further Reading

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Keywords

hypoxic-ischemic encephalopathy, neonatal Encephalopathy, hypothermia, HIE, perinatal asphyxia, birth asphyxia, neonatal asphyxia, hypoxia, acidosis, ischemia, cerebral blood flow, CBF, multiple organ failure, aspiration pneumonia, mental retardation, epilepsy, cerebral palsy, hemiplegia, paraplegia, quadriplegia, stupor coma, poor sucking, seizures, reperfusion injury, tricuspid regurgitation, pulmonary hypertension, renal failure, oliguria, tubular failure, electrolyte imbalances, necrotizing enterocolitis, delayed gastric emptying, thrombocytopenia, coagulopathy

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Contributor Information and Disclosures

Author

Santina A Zanelli, MD, Assistant Professor, Department of Pediatrics, Division of Neonatology, University of Virginia Health System
Santina A Zanelli, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Neuroscience, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Coauthor(s)

Dirk P Stanley, MD, Resident Physician, Department of Pathology, University of Virginia Health System
Disclosure: Nothing to disclose.

David Kaufman, MD, ECMO Director, Associate Professor of Pediatrics, Department of Pediatrics, Division of Neonatology, University of Virginia Health System
David Kaufman, MD is a member of the following medical societies: American Academy of Pediatrics, European Society for Paediatric Infectious Diseases, Medical Society of Virginia, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Ted Rosenkrantz, MD, Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Brian S Carter, MD, FAAP, Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Co-director, Pediatric Advance Comfort Team, Monroe Carell Jr Children's Hospital at Vanderbilt
Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, National Hospice and Palliative Care Organization, and National Perinatal Association
Disclosure: Nothing to disclose.

CME Editor

Carol L Wagner, MD, Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD, Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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