No social problems noted No past med hx Mother had spontaneous rupture of fetal membranes SB born on Needed to be resuscitated at birth

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2 No social problems noted No past med hx Mother had spontaneous rupture of fetal membranes SB born on Needed to be resuscitated at birth (included assisted vent) Had generalized edema and possible hypoxic-ischemic encephalopathy (HIE) d/t abruption and uterine rupture Pt was place on cool cap treatment

3 Definition: a condition in which the brain does not receive enough oxygen (1) Most often refers to injury sustained by newborns (1) Can be used to describe any injury from low oxygen(1)

4 Injury or complication during birth Respiratory failure Blocked or ruptured blood vessel Drug overdose Drowning Lack of oxygen due to smoke inhalation Diseases that cause paralysis of respiratory organs or muscles Extremely low blood pressure Strangulation Cardiac arrest High altitudes Choking Compression or injury to trachea that stops breathing Complications from general anesthesia NYU Langon Medical Center. Hypoxic Ischemic Encephalopathy Accessed at:

5 Risk factors: any injury, complication, or condition that causes the brain to have reduction in blood flow and oxygen deprivation (1) Symptoms: Mild case- Difficulty concentrating, poor judgment, poor coordination, euphoria, extreme lethargy (1) Severe case- Seizures, coma, no brain stem reflexes, only blood pressure and heart function reflexes are functioning (1) NYU Langon Medical Center. Hypoxic Ischemic Encephalopathy Accessed at: ttp://

6 May include CT scan MRI scan Electrocardiogram (EKG) Echocardiogram Blood tests (includes arterial blood gas and glucose levels) Electroencephalogram (EEG) Ultrasound Evoked potential test NYU Langon Medical Center. Hypoxic Ischemic Encephalopathy Accessed at:

7 Treatments: Life sustaining treatment Mechanical Ventilation Treatments for the circulatory system Seizure control Cooling Hyperbaric oxygen treatment Prevention: HIE is unexpected and cannot be prevented in most cases Can prevent long-term brain damage with CPR once oxygen supply has been reduced NYU Langon Medical Center. Hypoxic Ischemic Encephalopathy Accessed at:

8 The Cool Cap Decreases the metabolic demand(2) A drop of 1 C will decrease the cerebral metabolic rate by 6-7%(3) Cerebral metabolic rate is main determinant of cerebral blood flow (3) May provide improvement in O2 supply in ischemic areas of the brain (3)

9 May prolong therapeutic window after exposure to acute hypoxia-ischemia (2) Animal models show that small reductions in temperature of the brain have significant and long-lasting neuroprotective effect (2) Decreases intracranial pressure (3) May act as an anti-convulsant (3)

10 One of the most common causes of severe long-term neurologic deficits in children is hypoxic-ischemic cerebral injury during the time before, during, or after birth (4) Cerebral palsy (4) Neuronal injury through necrosis or apoptosis from hypoxia ischemia (4) The intensity of the insult may determine in which manner the cells die

11 Multiple studies appear to show similar benefits of IH A study by Shankaran et al. showed a decrease by approximately 20% of death or severe disability in infants that received whole-body IH than those in a control that did not receive IH Incidence of cerebral palsy in the IH group was lower than that of the control group by 11%

12 Cool cap was placed on 9/16 and removed on 9/19 Was weaned to room air on 9/18 Edema remained until cap was removed and resolved over a few hrs after cap removal

13 9/16 9/17 9/18 9/19 9/20 9/21 9/22 Wt (Kg) Wt (#) Wt %tile 9 Ht (cm) Ht (in) Ht %tile 60 OFC(cm) 35 OFC %tile 56

14 9/20 Norm Alb g/dl Gluc mg/dl Tpro g/dl Ca mg/dl Cl mmol/l K mmol/l Na mmol/l P mg/dl ALP (H) U/L ALT U/L AST U/L BUN 29.0 (H) 8-18 mg/dl Possible explanations: ALP may be elevated d/t time on TPN BUN elevated d/t stress of traumatic birth Elevated CO2 possibly d/t HIE and/or slight metabolic alkalosis Creat mg/dl CO (H)

15 NPO during IH Enteral feeds were given with 9 mls q 3 (MM per guidelines; PHM 1:1 Enf 20 if MM unavailable It was noted that they did skip on feeding guidelines d/t infant demands Date Diet Order 9/18 69mls/kg/d TPN (41 kcal/kg/d, 2.0 total pro, 0.6 total fat) 9/19 87 mls/kg/d TPN (60 kcal/kg/d, 3.4 total pro, 1.4 total fat) 9/ ml/kg/d (102 ml/kg/d TPN, 2.1 ml/kg/d enteral, 71 kcal/kg/d, 3.5 total pro, 1.8 total fat) 9/ ml/kg/d (99 ml/kg/d TPN, 6 ml/kg/d enteral, 79 kcal/kg/d, 3.0 total pro, 2.8 total fat) 9/ ml/kg/d (80 ml/kg/d TPN, 47 ml/kg/d enteral, 99 kcals/kg/d, 2.6 total pro, 4.8 total fat

16 Kcals: kcals/kg/d Protein: g/kg/d Fluid: mls/kg/d

17 Assessment: Pt estimated needs have not been met thus far. Expect needs to be met as pt is transitioned to full PO needs of Enfamil and/or PHM. Will monitor and watch ln, wt, ofc, and labs (BUN, Ca, P, and ALK) and make recommendations prn Problem: Inadequate oral intake r/t traumatic birth AEB cold cap tx and not yet nippling 100% of needs

18 Goals: 100% enteral feeds Meet nutrition needs for optimal growth Maintain intake mls/kg/d Intervention: PHM/MM 22 and TPN via IV and PO provide per kg: 98 mls, 84 kcals, 1.25 g protein, 26 mg Ca, 21 mg P, 0.02 mg Fe, and 70 units vitamin D Recommendations: Achieve and maintain intake mls/kg/d

19 SB was discharged a few days after assessment and was nippling 100% of enteral feeds and appeared to tolerate feeds well Any developmental delays will be revealed at a later age, but expect prognosis to be good

20 1. NYU Langone Medical Center. Hypoxic Ischemic Encephalopathy Accessed at: Accessed on Wyatt J, Thoresen M. Hypothermia Treatment and the Newborn. Pediatrics. 1997, 100(6): Bernard S, Buist M. Induced hypothermia in critical care medicine: A review. Critical Care Medicine. 2003, 31(7): Perlman J. Summary Proceedings from Neurology Group on Hypoxic- Ischemic Encephalopathy. Pediatrics. 2006, 117(3): S28-S33 5. Shankaran S, Laptook A, Ehrenkranz R, et al. Whole-Body Hypothermia for Neonates with Hypoxic Ischemic Encephalopathy. The New England Journal of Medicine. 2005, 353(15):