Birth Asphyxia/ Hypoxic Ischaemic Encephalopathy (HIE) (Chapter 8)

Learning Objectives

After completion of this chapter the participant should be able to:

Identify Hypoxic Ischaemic Encephalopathy.
Classify Hypoxic Ischaemic Encephalopathy.
Describe the management of babies who have Hypoxic Ischaemic Encephalopathy.

Hypoxic Ischemic Encephalopathy (HIE)

HIE is also called birth asphyxia and neonatal encephalopathy, and in this document, we will use the term HIE. HIE is very common in Malawi; therefore, the optimal management of these newborns is very important.

Lack of oxygen supply to organs before, during, or immediately after birth, results in HIE which is recognized by either delayed onset of breathing or crying. Clinical features that evolve in these babies over the first 2-3 days of life include irritability, lethargy or coma, hypotonia or hypertonia of the muscles, convulsions, apnoea, temperature instability, poor suck, and feeding difficulty. The diagnosis in preterm infants is difficult, as they may be hypotonic because of prematurity.

Suspect HIE in a baby with some/all of the following:

Foetal bradycardia
Prolonged second stage of labour
Required bag and mask ventilation for > 5 min
Required cardiac massage
Irritable, hypotonic, seizures, poor suck, poor colour
High lactate on cord blood

APGAR scores <7 at 5 minutes

Scoring System for APGAR Score

Classification of Severity of Hypoxic Ischaemic Encephalopathy (HIE)

Classify the degree of Hypoxic Ischaemic Encephalopathy (HIE) according to the table below. Babies with mild and moderate HIE generally have a good prognosis and do well. A newborn who, within a week of birth, is still floppy or spastic, unresponsive, and cannot suck has severe brain injury and will do poorly.

Feature	Mild	Moderate	Severe
Consciousness	Irritability	Lethargy	Comatose
Tone	Hypotonia	Marked hypotonia	Severe hypotonia
Seizures	No	Yes	Prolonged
Sucking/ respiration	Poor suck	Unable to suck	Unable to sustain adequate regular spontaneous respiration

Distinguishing Between Convulsions and Jitteriness

Most children with HIE present with convulsion; however, these are often subtle and need to be differentiated from jitteriness. The table below shows how convulsions can be differentiated from jitteriness.

Convulsions	Jitteriness
Have both fast and slow components; slow movements (1-3 jerks per second).	Fast movements (4-6 per second); tremors are of equal amplitude.
Not provoked by stimulation.	Provoked by stimulation.
Does not stop with restraint.	Stops with restraint.
Neurological examination often abnormal.	Neurological examination usually normal.
Often associated with eye movements (tonic deviation of the pupil) or blinking.	Not associated with eye movements or autonomic changes.

Management of Birth Asphyxia/HIE

Zoom in for details.

Management of convulsions

Key Facts for Providers: Supportive Management of Birth Asphyxia
Check for emergency signs ABC and provide emergency care. Place these babies under a radiant warmer to maintain normal temperature but prevent hyperthermia. Check blood glucose and if hypoglycaemia is detected, treat. If not hypoglycaemic check blood glucose every 12 hours. Fluids: In a baby with emergency signs (breathing difficulty, shock, coma or convulsions), provide maintenance intravenous fluids using wall charts and according to age after initial stabilization of emergency signs. Feeding: If the baby has neither emergency signs nor abdominal distension, consider enteral feeding. If the baby is sucking well, initiate breast feeding or initiate tube feeding with breast milk in those with poor/no sucking using wall charts to determine the volume.

Key Facts for Providers:
Supportive Management of Birth Asphyxia

Check for emergency signs ABC and provide emergency care.
Place these babies under a radiant warmer to maintain normal temperature but prevent hyperthermia.
Check blood glucose and if hypoglycaemia is detected, treat. If not hypoglycaemic check blood glucose every 12 hours.
Fluids: In a baby with emergency signs (breathing difficulty, shock, coma or convulsions), provide maintenance intravenous fluids using wall charts and according to age after initial stabilization of emergency signs.
Feeding: If the baby has neither emergency signs nor abdominal distension, consider enteral feeding. If the baby is sucking well, initiate breast feeding or initiate tube feeding with breast milk in those with poor/no sucking using wall charts to determine the volume.

Documentation, Discharge and Follow-up

Document in health passport and classify HIE as mild, moderate, or severe.

If severe, arrange for a physiotherapy appointment (initially floppy infants often become stiff requiring the mother to learn massage and basic physiotherapy skills) and follow up at six months - focus on head growth, general health, and motor neurodevelopment. Assessments at 12 to 24 months focus on cognitive skills and language development.