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Hypoxic Ischemic Encephalopathy

Table of Contents

Hypoxic Ischemic Encephalopathy

HIE; Neonatal Hypoxic Ischemic Encephalopathy; Neonatal HIE; NHIE; Neonatal Encephalopathy

Hypoxic ischemic encephalopathy (HIE) is an umbrella term for a brain injury that happens before, during, or shortly after birth when oxygen or blood flow to the brain is reduced or stopped. Babies born with HIE may have neurological or developmental problems. Learn more about symptoms, risk factors and treatment.

Newborn Intensive Care Units (NICU)

Image by Engin Akyurt

About

Cerebral Hypoxia

Image by Hellerhoff

Cerebral Hypoxia

CT in a person after generalized hypoxia.

Image by Hellerhoff

What Is Hypoxic Ischemic Encephalopathy?

Hypoxic ischemic encephalopathy (HIE) is an umbrella term for a brain injury that happens before, during, or shortly after birth when oxygen or blood flow to the brain is reduced or stopped.

While some children who experience HIE at birth may not have any long-term consequences, others can experience mild to severe disabilities or even death. The severity of HIE-related issues depends on many factors, including:

How long the brain is without oxygen or blood flow
How much of the brain is affected
How the individual’s brain repairs itself

Source: National Institute of Neurological Disorders and Stroke (NINDS)

Additional Materials (4)

Watch Brain Damage And Hypoxia - What Is Cerebral Hypoxia?

Video by DailyNewsAmerica/YouTube

"Therapeutic Hypothermia: Treatment of Hypoxic Ischemic Encephalopathy Part 2" by Denise Casey

Video by OPENPediatrics/YouTube

Patient Profile - Rains Malone, Infant Hypoxic Ischemic Encephalopathy

Video by East Tennessee Children's Hospital/YouTube

What is hypoxic ischemic encephalopathy?

Video by BabyFirstChannel/YouTube

1:09

Watch Brain Damage And Hypoxia - What Is Cerebral Hypoxia?

DailyNewsAmerica/YouTube

10:37

"Therapeutic Hypothermia: Treatment of Hypoxic Ischemic Encephalopathy Part 2" by Denise Casey

OPENPediatrics/YouTube

1:31

Patient Profile - Rains Malone, Infant Hypoxic Ischemic Encephalopathy

East Tennessee Children's Hospital/YouTube

2:36

What is hypoxic ischemic encephalopathy?

BabyFirstChannel/YouTube

Symptoms

Highrisk neonate - severe birth asphyxia, hypoxic ischemic encephalopathy II- in HRB clinic

Image by Bhakua

Highrisk neonate - severe birth asphyxia, hypoxic ischemic encephalopathy II- in HRB clinic

Image by Bhakua

What Are the Signs and Symptoms of Hypoxic Ischemic Encephalopathy?

Encephalopathy, or a decrease in blood flow or oxygen to the brain, can affect many different organs, not just the brain. Individuals with HIE may have heart, lung, kidney, or liver problems.

Immediately during or after the brain injury, the infant or child may have the following symptoms:

Low heart rate
Breathing problems
Too much acid in body fluids (acidosis)
Seizures or unusual movements
Stained meconium (a newborn’s first stool)
Low muscle tone
Blue or very pale skin
Low reflexes

Individuals with HIE may be diagnosed with perinatal encephalopathy, perinatal asphyxia, neonatal encephalopathy, or birth asphyxia. Health problems that result from HIE typically occur in two stages: when the brain is initially deprived of oxygen and blood, and when normal blood flow returns and toxins are dispersed from the damaged cells (this is called reperfusion injury and usually occurs six to 48 hours after the initial trauma).

Brain injuries from HIE can cause:

Developmental delays
Intellectual disabilities
Epilepsy
Cerebral palsy
Heart problems or cardiac arrest

The extent of the damage in HIE may not be understood for several months or years after the brain injury occurs. Sometimes, issues are not identified until the child begins attending school.

Source: National Institute of Neurological Disorders and Stroke (NINDS)

Risk Factors

Preeclampsia disproportionately impacts pregnant Black women in the U.S.

Image by StoryMD/Pexels

Preeclampsia disproportionately impacts pregnant Black women in the U.S.

Black women are 3 times more likely to experience preeclampsia than white women.

Image by StoryMD/Pexels

Who Is More Likely to Get Hypoxic Ischemic Encephalopathy?

While most cases of HIE cannot be prevented, some factors can make HIE more likely. Those include:

Preeclampsia (high blood pressure) in the child’s birth mother, or low blood pressure during delivery
Issues with the umbilical cord, uterus, or placenta
Maternal infections or infections in the fetus or newborn
Heart or lung problems
Anemia in the fetus
Internal bleeding by the birth mother and fetus
Problems during labor and delivery that restrict blood flow to the infant
Very premature births
Physical trauma to the brain or skull
Poor positioning during delivery (ex: shoulders getting stuck for prolonged periods during delivery)

Source: National Institute of Neurological Disorders and Stroke (NINDS)

Diagnosis

Aneurysm in a cerebral artery, one cause of hypoxic anoxic injury (HAI).

Image by Lucien Monfils

Aneurysm in a cerebral artery, one cause of hypoxic anoxic injury (HAI).

Aneurysm in a cerebral artery, one cause of hypoxic anoxic injury (HAI).

Image by Lucien Monfils

How Is Hypoxic Ischemic Encephalopathy Diagnosed?

Diagnostic tests such as blood tests, spinal fluid tests, imaging tests (MRIs, ultrasounds), electroencephalograms (EEGs), and similar tools may be used to determine the causes of brain injuries. In newborns, an APGAR test, which looks at an infant’s skin color, heart rate, reflexes, muscle tone, and breathing, is used to assess an infant’s overall health and can help identify neonatal distress.

Source: National Institute of Neurological Disorders and Stroke (NINDS)

Apgar Evaluation

Apgar Evaluation

Also called: Newborn Scoring, Delivery - Apgar, Apgar Score, Apgar test, Apgar

Apgar is the first test given to newborns immediately after birth. It is usually done twice: one minute and five minutes from the time of birth. Apgar stands for: Appearance, Pulse, Grimace, Activity, and Respiration.

Apgar Evaluation

Also called: Newborn Scoring, Delivery - Apgar, Apgar Score, Apgar test, Apgar

Apgar is the first test given to newborns immediately after birth. It is usually done twice: one minute and five minutes from the time of birth. Apgar stands for: Appearance, Pulse, Grimace, Activity, and Respiration.

{"label":"Apgar Evaluation Reference Range","scale":"lin","step":1,"hideunits":false,"items":[{"flag":"abnormal","label":{"short":"Severe distress","long":"Severe distress","orientation":"horizontal"},"values":{"min":0,"max":4},"text":"The lower the score, the more help the baby needs to adjust outside the mother's womb.","conditions":[]},{"flag":"borderline","label":{"short":"Moderate distress","long":"Moderate distress","orientation":"horizontal"},"values":{"min":4,"max":7},"text":"Any score lower than 7 is a sign that the baby needs medical attention. ","conditions":[]},{"flag":"normal","label":{"short":"Normal","long":"Normal","orientation":"horizontal"},"values":{"min":7,"max":10},"text":"An Apgar score of 7 to 10 predicts an absence of difficulty in adjusting to the environment outside the mother's womb. A score of 10 is very unusual, since almost all newborns lose 1 point for blue hands and feet, which is normal for after birth.","conditions":[]}],"value":9}[{"abnormal":0},{"borderline":0},{"normal":0}]
Use the slider below to see how your results affect your health.
4
7
Your result is Normal.
An Apgar score of 7 to 10 predicts an absence of difficulty in adjusting to the environment outside the mother's womb. A score of 10 is very unusual, since almost all newborns lose 1 point for blue hands and feet, which is normal for after birth.
Related conditions
The Apgar test is a quick way for doctors to figure out if the baby is healthy or needs extra medical care. Apgar tests are usually done twice: one minute after birth and again five minutes after birth. Doctors and nurses measure five signs of the baby's condition. These are:
- Heart rate
- Breathing
- Activity and muscle tone
- Reflexes
- Skin color
The Apgar score was introduced in 1952 by the anesthesiologist Dr. Virginia Apgar as a method to assess the effects on the newborn of anesthesia given to the laboring mother. Healthcare providers now use it to assess the general wellbeing of the newborn, whether or not analgesics or anesthetics were used.
Five criteria—skin color, heart rate, reflex, muscle tone, and respiration—are assessed, and each criterion is assigned a score of 0, 1, or 2. Each time that scores are taken, the five scores are added together.
The score is calculated as follows:
Breathing effort
- If the infant is not breathing, the respiratory score is 0.
- If respirations are slow and irregular, weak or gasping, the respiratory score is 1.
- If the infant is crying vigorously, the respiratory score is 2.
Heart rate
Heart rate is evaluated with a stethoscope and is the most critical part of the score in determining the need for immediate medical attention to resuscitate or stabilize the newborn.
- If there is no heartbeat, the heart rate score is 0.
- If the heart rate is less than 100 beats per minute, the heart rate score is 1.
- If the heart rate is more than 100 beats per minute, the heart rate score is 2.
Muscle tone
- If the muscle tone is loose and floppy without activity, the score for muscle tone is 0.
- If the infant demonstrates some tone and flexion, the score for muscle tone is 1.
- If the infant is in active motion with flexed muscle tone that resists extension, the score for muscle tone is 2.
Grimace response or reflex irritability in response to stimulation
- If there is no response to stimulation, the reflex irritability response score is 0.
- If there is grimacing in response to stimulation, the reflex irritability response score is 1.
- If the infant cries, coughs or sneezes on stimulation, the reflex irritability response is 2.
Color
Most infants will score 1 for color as peripheral cyanosis (blue hands and feet) is common among normal infants. Color can also be misleading in non-white infants.
- If the infant is pale or blue, the score for color is 0.
- If the infant is pink, but the extremities are blue, the score for color is 1.
- If the infant is completely pink, the score for color is 2.
1. Your baby's first hours of life. Office on Women's Health in the Office of the Assistant Secretary for Health. [accessed on Jan 09, 2019]
2. Apgar score. MedlinePlus Medical Encyclopedia. [accessed on Jan 09, 2019]
3. Adjustments of the Infant at Birth and Postnatal Stages. OpenStax, Anatomy & Physiology. OpenStax CNX. Feb 26, 2016. [accessed on Jan 09, 2019]
4. Simon LV, Bragg BN. APGAR Score. [Updated 2018 Dec 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. [accessed on Jan 09, 2019]
5. KidsHealth.org / What Is the Apgar Score? [accessed on Jan 09, 2019]

Normal reference ranges can vary depending on the laboratory and the method used for testing. You must use the range supplied by the laboratory that performed your test to evaluate whether your results are "within normal limits."

Additional Materials (18)

Neonatal Circulatory System

A newborn’s circulatory system reconfigures immediately after birth. The three fetal shunts have been closed permanently, facilitating blood flow to the liver and lungs.

Image by CNX Openstax

Newborn

A single fertilized egg develops over the span of nine months into an infant consisting of trillions of cells and capable of surviving outside the womb. (credit: “Seattleye”/flickr.com)

Image by CNX Openstax (credit: “Seattleye”/flickr.com)

What is Apgar Score?

Video by Medical Centric/YouTube

APGAR Scoring System

Video by Med School Made Easy/YouTube

APGAR Newborn Assessment Score Scale Test Made Easy w/ NCLEX Practice Questions

Video by RegisteredNurseRN/YouTube

APGAR Score - MEDZCOOL

Video by Medzcool/YouTube

Understanding APGAR score, the best explanation with a mnemonic!

Video by Medicosis Perfectionalis/YouTube

Apgar Score Assessment (Appearance, Pulse, Grimace, Activity and Respiration)

Video by USMLE pass/YouTube

Neonatal reflexes | Behavior | MCAT | Khan Academy

Video by khanacademymedicine/YouTube

Apgar Score: Implications and Limitations

Video by Medical Education for Visual Learners/YouTube

NYP It Happened Here: The Apgar Score

Video by NewYork-Presbyterian Hospital/YouTube

"Newborn Exam" by Nina Gold for OPENPediatrics

Video by OPENPediatrics/YouTube

Newborn Physical Exam – Pediatrics | Lecturio

Video by Lecturio Medical/YouTube

Neonatal Assessment

Video by East Carolina University College of Nursing/YouTube

APGAR score

The chart says how to calculate apgar score for an infant.

Image by Dr.Vijaya chandar/Wikimedia

Micole Dmochowska's birth card with apgar test results

Micole Dmochowska's birth card with apgar test results Image by Eve Dmochowska

Image by https://commons.wikimedia.org/wiki/File:Micole_Dmochowska.jpg

Virginia Apgar, American physician who introduced the Apgar Score.

Virginia Apgar, American physician who introduced the Apgar Score. Image by World Journal Tribune photo by Al Ravenna

Image by https://af.m.wikipedia.org/wiki/L%C3%AAer:Virginia_Apgar.jpg

Apgar Score Rates

Apgar Score Rates

Image by TheVisualMD

Neonatal Circulatory System

CNX Openstax

Newborn

CNX Openstax (credit: “Seattleye”/flickr.com)

4:46

What is Apgar Score?

Medical Centric/YouTube

7:00

APGAR Scoring System

Med School Made Easy/YouTube

9:15

APGAR Newborn Assessment Score Scale Test Made Easy w/ NCLEX Practice Questions

RegisteredNurseRN/YouTube

2:58

APGAR Score - MEDZCOOL

Medzcool/YouTube

9:10

Understanding APGAR score, the best explanation with a mnemonic!

Medicosis Perfectionalis/YouTube

1:59

Apgar Score Assessment (Appearance, Pulse, Grimace, Activity and Respiration)

USMLE pass/YouTube

5:13

Neonatal reflexes | Behavior | MCAT | Khan Academy

khanacademymedicine/YouTube

0:53

Apgar Score: Implications and Limitations

Medical Education for Visual Learners/YouTube

1:57

NYP It Happened Here: The Apgar Score

NewYork-Presbyterian Hospital/YouTube

16:41

"Newborn Exam" by Nina Gold for OPENPediatrics

OPENPediatrics/YouTube

9:47

Newborn Physical Exam – Pediatrics | Lecturio

Lecturio Medical/YouTube

32:15

Neonatal Assessment

East Carolina University College of Nursing/YouTube

APGAR score

Dr.Vijaya chandar/Wikimedia

Micole Dmochowska's birth card with apgar test results

https://commons.wikimedia.org/wiki/File:Micole_Dmochowska.jpg

Virginia Apgar, American physician who introduced the Apgar Score.

https://af.m.wikipedia.org/wiki/L%C3%AAer:Virginia_Apgar.jpg

Apgar Score Rates

TheVisualMD

Treatment

Fitting a young girl with a hearing aid

Image by Biha

Fitting a young girl with a hearing aid

Fitting a young girl with a hearing aid

Image by Biha

How Is Hypoxic Ischemic Encephalopathy Treated?

There is no one treatment for infants and children with HIE. Treating the underlying cause of the disorder may improve symptoms. However, encephalopathy may cause permanent structural changes and irreversible damage to the brain.

Doctors may perform a cooling treatment (called therapeutic hypothermia), by which the infant’s brain and body are cooled down to reduce further injury and help protect the brain from the effects of losing oxygen and blood flow. This treatment may reduce the likelihood of severe disability and death.

Individuals whose heart, lungs, kidneys, or liver are damaged by HIE may receive treatments for their organ damage. Other treatments for HIE depend on the symptoms, severity, and the age of the child and may include:

Physical, speech, or occupational therapy
Feeding or swallowing therapy
Vision therapy, eyeglasses, or other corrective devices
Hearing therapy or hearing aids
Medications to prevent seizures (called anticonvulsants)

Scientists are studying interventions to help infants’ and children’s brains adapt and recover from injury (improving their neuroplasticity) and exploring novel treatments to improve outcomes for infants with HIE, including hormones, supplements, and stem cell treatments that may one day help the brains of people with HIE recover. Further research is needed to understand how care teams can best treat and support individuals with HIE.

Source: National Institute of Neurological Disorders and Stroke (NINDS)

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Hypoxic Ischemic Encephalopathy

Hypoxic ischemic encephalopathy (HIE) is an umbrella term for a brain injury that happens before, during, or shortly after birth when oxygen or blood flow to the brain is reduced or stopped. Babies born with HIE may have neurological or developmental problems. Learn more about symptoms, risk factors and treatment.

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