Hypothermic Brain Cooling Attorneys Discuss Treatment for Hypoxic Ischemic Encephalopathy: Neonatal Requirements
Trusted Hypoxic Ischemic Encephalopathy (HIE) Lawyers & Hypothermic Brain Cooling Attorneys
When babies experience a traumatic birth or have difficult stays in the neonatal intensive care unit (NICU), they may experience oxygen deprivation. This type of neonatal injury, which is known as hypoxic ischemic encephalopathy (HIE), is caused by oxygen deprivation and limited blood flow to the baby’s brain at or near the time of birth. Cell death and subsequent brain damage occur when the brain does not receive adequate oxygenation. Currently, the only known treatment for HIE is called hypothermia therapy (also known as body cooling, brain cooling, therapeutic hypothermia, or hypothermia treatment). When hypothermic brain cooling begins within six hours of the oxygen-depriving insult, it slows down nearly every damaging event that starts to occur when the brain is deprived of oxygen. Hypothermia therapy can help decrease the severity of (or even prevent) permanent brain damage that causes debilitating conditions such as crebral palsy. Research shows that when hypothermia treatment is promptly given after an oxygen-depriving insult, the incidence of death and cerebral palsy is significantly reduced. Therefore, hypothermia treatment is the standard of care when a diagnosis of hypoxic ischemic encephalopathy has been made. The key is for physicians to make the diagnosis soon after the event occurred that caused the baby’s brain to suffer from a lack of oxygen. A baby must have been born after 36 weeks of gestation to be eligible for hypothermia therapy. Throughout this page, our HIE and hypothermic brain cooling attorneys will explain everything you need to know about hypoxic ischemic encephalopathy, hypothermia therapy and birth injury.
Causes of Hypoxic Ischemic Encephalopathy (HIE) and Indications for Hypothermic Brain Cooling
Hypoxic ischemic encephalopathy (HIE) is caused by a lack of oxygen in the baby’s blood (and brain tissue), called hypoxia, and/or a lack of blood flow in the baby’s brain, called ischemia. There are many events that can occur during or near the time of birth that can cause a lack of oxygen to the baby’s brain. Sometimes these events occur shortly before birth, when signs of a serious condition affecting the baby are present, but the medical team fails to quickly act and help the baby. Other times, traumatic events occur during labor and delivery and the baby isn’t delivered quickly enough, which often has to occur by cesarean (C-section) delivery. Then, there are times when the baby is in the NICU and the medical team fails to properly manage the baby’s breathing, causing the baby to have severe oxygen-depriving events and/or long-term (chronic) oxygen deprivation.
During delivery, a baby’s heart rate must be closely monitored by a fetal heart rate monitor. When a baby is experiencing a lack of oxygen to the brain, it will show up on the monitor as an abnormal (non-reassuring) heart tracing. During pregnancy, mothers have regular prenatal testing performed that check the how well the baby is doing, and this includes examination of the baby’s heart rate as well as other conditions that can affect oxygenation and heart rates in the future. These tests are performed to assess factors such as the amniotic fluid and the baby’s response to stimulation.
Conditions that can cause a lack of oxygen to the baby’s brain and hypoxic ischemic encephalopathy (HIE) include the following:
- Ruptured uterus (womb)
- Failure to quickly deliver a baby when fetal distress is evident on the fetal heart rate monitor (delayed emergency cesarean delivery/C-section)
- Umbilical cord problems, such as a nuchal cord (cord wrapped around the baby’s neck), umbilical cord prolapse, short cord and a true knot in the cord
- Oligohydramnios (low amniotic fluid)
- Premature rupture of the membranes (PROM)
- Premature birth
- Preeclampsia / eclampsia
- Postmaturity syndrome
- Placental abruption
- Prolonged and arrested labor
- Placenta previa
- Intracranial hemorrhages (brain bleeds), which can be caused by a traumatic delivery. Forceps and vacuum extractors can cause brain bleeds. Sometimes intense contractions (hyperstimulation) caused by labor induction drugs (Pitocin and Cytotec) can cause head trauma. Mismanagement of cephalopelvic disproportion (CPD), abnormal presentations (face or breech presentation), and shoulder dystocia also put a child at risk of having a brain bleed and oxygen deprivation.
- Hyperstimulation caused by Pitocin and Cytotec can also cause oxygen deprivation that gets progressively worse.
- Improper management of the baby’s breathing (respiratory status) after birth. This includes failure to properly manage apnea (periods in which the baby stops breathing), failure to properly manage a baby on a breathing machine (which can cause overventilation injuries, such as hypocarbia and holes in the lungs), and failure to give proper amounts of surfactant, which help with lung maturity and lung compliance in premature lungs.
- Anesthesia mistakes, which can cause blood pressure problems in the mother, including a hypotensive crisis.
- Improper management of anemia (low red blood cell count), which can cause the baby to lack the capacity to carry oxygen to the cells and tissues in the body, including brain cells.
- Fetal stroke
- A brain infection such as meningitis, which can be caused by infections in the mother that travel to the baby at birth. These maternal infections include the following: Group B Strep (GBS), herpes simplex virus (HSV), urinary tract infection (UTI), bacterial vaginosis (BV) and chorioamnionitis
Treatment for Hypoxic Ischemic Encephalopathy (HIE): Neonatal Hypothermic Brain Cooling
The medical team must closely monitor a baby who is at risk for having an oxygen-depriving insult, and this includes the time period during labor and delivery, as well as the time a baby is in the NICU. If there is any possibility that a baby suffered a lack of oxygen in the brain, it is crucial for the medical team to closely monitor the baby for signs of hypoxic ischemic encephalopathy (HIE). The reason this is crucial is because therapeutic hypothermia is not given unless a diagnosis of HIE has officially been made. If a diagnosis is not promptly made, a baby may not receive hypothermia treatment, which means the brain injury may be much more severe than it would have been with the treatment, which can result in the child having cerebral palsy. The more severe the HIE, the sooner the hypothermia therapy must be started, and it must be initiated within six hours* of the oxygen-depriving insult. Indeed, failure to promptly diagnose HIE is medical negligence.
Signs and Symptoms of Hypoxic Ischemic Encephalopathy (HIE)
It is critical for the medical team to closely monitor the baby for signs of hypoxic ischemic encephalopathy so that a quick diagnosis of HIE can be made and hypothermia treatment can be started as soon as possible. As mentioned before, hypothermic brain cooling cannot begin unless a diagnosis of hypoxic ischemic encephalopathy has been made.
Signs and symptoms of hypoxic ischemic encephalopathy:
- The need for neonatal resuscitation at birth or at any time during the neonatal period could indicate hypoxic ischemic encephalopathy.
- Low APGAR scores for longer than 5 minutes often indicate that the baby has HIE. An APGAR score assesses the overall health of a newborn over the first few minutes of life. It assigns scores to factors such as the baby’s skin color (complexion(, pulse rate, reflexes, muscle tone and breathing.
- Seizures within the first 24-48 hours of delivery are one of the most common indicators of HIE caused by an event during birth, and seizures while in the NICU or shortly after discharge from the NICU are an indication of an oxygen depriving insult that occurred after birth. HIE is a leading cause of neonatal seizures.
- Difficulty feeding, including the inability to latch, suck or swallow, may be a sign of hypoxic ischemic encephalopathy.
- Profound metabolic or mixed acidemia in an umbilical cord blood sample (the baby’s blood is acidic/has a low pH.) is commonly associated with HIE.
- Abnormal limpness
- Multiple organ problems (for instance, involvement of the lungs, liver, heart, intestines) commonly indicates that a hypoxic-ischemic event occurred at or around the time of delivery.
- Absent brain stem reflexes (for instance, breathing problems and an abnormal response to light, and only blood pressure and heart function reflexes are functioning)
- Coma in a newborn baby can indicate the presence of hypoxic ischemic encephalopathy.
- Hypotonia (low muscle tone) commonly indicates that a newborn baby has HIE.
Neonatal Requirements for Therapeutic Hypothermia (Neonatal Brain Cooling)
Although diagnosing hypoxic ischemic encephalopathy can be a complicated process, medical professionals are obligated to diagnose it quickly (in less than six hours from the time of the injury) in order to begin hypothermia therapy. To diagnose HIE, many hospitals use the same eligibility criteria that the original researchers used when studying the effects of hypothermic brain cooling on babies with HIE. In this section, our HIE and brain cooling attorneys will discuss the eligibility requirements used to diagnose HIE and begin hypothermia therapy.
Clinical Trial Criteria for Hypothermia Therapy
- Gestational age greater than 36 weeks
- Evidence of seizures or neonatal encephalopathy (global brain injury) by a standard neurological exam
- pH is less than 7 or base deficit is 16 or greater in umbilical cord arterial blood
- If pH is 7.01 – 7.15, base deficit is 10 – 15.9, or a blood gas sample is not available, the additional criteria are required:
- A sudden event during labor such as non-reassuring fetal heart tones (late or variable decelerations) umbilical cord prolapse or rupture, uterine rupture, maternal trauma, hemorrhage or cardio-respiratory arrest AND either a 10 minute Apgar score of 5 or less or assisted ventilation (baby is on a breathing machine or is being bagged) at birth that lasts 10 minutes or more
Criteria for Hypothermia Therapy Recommended by AAP, VA Chapter
Most hospitals vary at least slightly on the qualifications for hypothermia treatment. Listed below are the requirements used by the American Academy of Pediatrics, Virginia Chapter.
A. Infants >35 weeks gestation with ONE of the following:
- Apgar score of < 5 at 10 minutes after birth
- Continued need for resuscitation, including endotracheal or mask ventilation, at 10 minutes after birth
- Acidosis defined as either umbilical cord pH or any arterial pH within 60 minutes of birth less than 7.00
- Base Deficit > 16 mmol/L in umbilical cord blood sample or any blood sample within 60 minutes of birth (arterial or venous blood)
If the infant meets criteria A, then medical personnel assess for neurological abnormality:
B. Moderate to severe encephalopathy (Sarnat 2 or 3) consisting of an altered state of consciousness (as shown by lethargy, stupor, or coma) and at least one or more of the following:
- Abnormal reflexes, including oculomotor or pupillary abnormalities
- Absent or weak suck
Early diagnosis of hypoxic ischemic encephalopathy (HIE) is imperative so that brain cooling can be started right away. Physicians at different hospitals may use varying methods for diagnosis of HIE. The key is for them to recognize signs of HIE, quickly diagnose the condition, and then begin hypothermia treatment. If the baby meets the criteria for hypothermia treatment listed above, the therapy should be started right away. Of course, if a diagnosis is made without all the criteria being met, hypothermia treatment should still be given, as long as the baby was born at or later than 36 weeks (greater than 35 weeks at some hospitals), the oxygen-depriving insult occurred within the 6 hour time frame, and there are no contraindications to the treatment. Hypothermia treatment is very easy to give, and as of yet, researchers have not seen harmful effects of the therapy when it is properly implemented.
*Research Update: Hypothermia Therapy May Be Effective 6-24 Hours After Birth
A recently-published study in the Journal of the American Medical Association (JAMA) suggests that hypothermia therapy may be effective 6-24 hours after birth. Laptook et al. (2017) conducted a randomized clinical trial of infants with moderate or severe HIE. 83 infants were given hypothermia therapy, while 85 were maintained at a normal body temperature (control group). The authors then followed up with these cohorts between 18 and 22 months of age. Their results were non-significant under traditional frequentist analysis, but they suggested that hypothermia therapy may still be helpful more than six hours after birth. Laptook et al. stress that further research is warranted, because an improved prognosis in even a small percentage of patients could be of clinical importance due to the severity of HIE-related brain damage. Moreover, they found “no evidence of commensurate harm” – in other words, the potential benefits of administering hypothermia therapy between 6-24 hours may outweigh the costs.
Legal Help for Hypoxic Ischemic Encephalopathy: Hypothermic Brain Cooling Attorneys
If your child underwent therapeutic hypothermia and now has a permanent disability, such as HIE, cerebral palsy, seizures, an intellectual disability or developmental delay, the medical team may have engaged in negligent behavior. If your child has conditions such as HIE or cerebral palsy and hypothermia treatment was not given, this may also be negligent. Sometimes a diagnosis of HIE is made and hypothermia treatment is either improperly given or not given at all. Sometimes hypothermia therapy is properly given but the child still suffers from permanent brain damage. The award-winning hypoxic ischemic encephalopathy (HIE) lawyers at Reiter & Walsh ABC Law Centers have been helping children with birth injuries for decades and have the skill and experience to carefully review medical records to determine if medical malpractice caused a child’s injury.
Birth injury is a difficult area of law to pursue due to the complex nature of the medical records. The award winning hypoxic ischemic encephalopathy (HIE) lawyers at Reiter & Walsh ABC Law Centers have decades of experience with birth injury cases. To find out if you have a case, contact our nationally recognized Michigan law firm to speak with an experienced attorney. We handle cases in Michigan, Ohio, Washington, D.C. and throughout the nation. We have numerous multi-million dollar verdicts and settlements that attest to our success and no fees are ever paid to our firm until we win your case. Email or call our hypoxic ischemic encephalopathy (HIE) lawyers at 888-419-2229.
In this video, hypoxic ischemic encephalopathy (HIE) lawyers Jesse Reiter and Rebecca Walsh talk about how a lack of oxygen to the brain at or near the time of birth can cause permanent brain injury such as hypoxic ischemic encephalopathy (HIE), seizures and cerebral palsy.