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To cool or not to cool. That is the question. When a baby is born with possible hie or P or gasses, it can often feel like a tough decision as unnecessary cooling will be extremely invasive for the baby and potentially lead to medical complications. But equally withholding cooling can lead to fears that a future cerebral palsy diagnosis will lead to your management being questioned. Whilst there are no easy answers to these issues. In this video, we will learn all about cooling criteria, how to perform a neonatal neurological examination and how to determine if a baby has clinical hie. I'm Doctor Matthew Sayers, a consultant, pediatrician with over 10 years experience in pediatrics and I have treated a number of babies with hie both in the neonatal period and subsequently with epilepsy and neurodevelopmental delay. In this video. I will share my experience and tips on how to assess a baby with suspected hie. Thanks to all guidelines and documents in this video are available in the video description and also on the OA medical app. Hypoxic Ischemic encephalopathy is a condition in which the baby's brain and other organs are starved of oxygen due to an hypoxic event at the time of birth. This leads to neurological impairment in the form of reduced level of consciousness, poor tone and seizures which can persist causing permanent brain damage with developmental delay, cerebral palsy and epilepsy. Various studies including the Toby trial have demonstrated that initiating whole body cooling of a newborn with moderate or severe hie for 72 hours, significantly reduces the combined outcome of mortality and neurodevelopmental disability. At 18 months of age cooling is performed in a neonatal intensive care unit with specialist cooling blankets and rectal thermometers and the baby must be closely monitored while this goes on. In this video, we will consider the case of a 39 week gestation baby born by normal vaginal delivery. It was shoulder dystocia at delivery with entrapment for six minutes. When the baby was born, they were pale floppy and apneic and had a heart rate of less than 60. But after five inflation breaths, regular breathing was established and the heart rate is now greater than 100. They remain very floppy and quiet. And the midwife has asked you to review them. Their birth weight is 4.5 kg and their core grasses show a ph of 6.9 and a base excess of minus 20 a ph of 7.2 base excess minus 15. In order to commence therapeutic cooling, the baby must be over 36 weeks gestation and must be less than six hours old. There are then three additional criteria that must be met criteria. A deals with the hypoxic ischemic element and there are a number of clinical and investigation factors that can increase the likelihood of a hypoxic ischemic insult occurring at delivery criteria. B consists of the clinical assessment of encephalopathy. The baby must have reist alertness as well as one of altered reflexes, reist tone, reist suck or seizures to meet criteria. B criteria. C uses cerebral function analysis monitoring to make an amplified e eg diagnosis of encephalopathy. We will examine all three of these criteria in detail. In this video, babies should be greater than 36 weeks, gestation, greater than 1800 g and less than six hours old to meet criteria for proving it should not be performed if the baby has other major congenital abnormalities, a significant skull fracture, life threatening hemorrhage or if death appears inevitable. If you're unsure about any of these discuss with a senior neonatologist, we firstly need to consider if the baby has features in keeping with the perinatal hypoxic ischemic event, we will consider clinical features and blood gas features. And I'll summarize these below. If there is an apgar score of five or less or an ongoing need for resuscitation of 10 minutes of life, or if there is a ph less than seven or a base deficit of 16 or more on any blood gas within 60 minutes of birth. In this case, we can see that the baby does meet criteria A for cooling as their blood gas is less than seven and their base deficit is greater than 16. Now that you've completed your assessment of criteria A, you can now move on to criteria B. Criteria B consists of a clinical assessment of encephalopathy. And we will look at this in depth in this video to meet criteria B, the baby must have reduced alertness as well as one of altered reflexes, reist tone reist suck or seizures to meet criteria. B, it can be helpful to adopt a top to toe approach which can be integrated into the general systemic examination of a newborn. Note that these clinical features um identify general neonatal encephalopathy. But hypoxic ischemic encephalopathy is not the only form of encephalopathy. Other forms of encephalopathy such as metabolic epileptic or uremic can occur. Firstly, examine the baby's level of responsiveness and activity. Normally babies will be alert or will awaken easily. Babies that are lethargic or unconscious and do not waken easily. When examined may have encephalopathy. Examine the baby's eyes. What size are the pupils? And are they reactive to light constricted dilated or unreactive pupils? May indicate encephalopathy move the baby's head from side to side and examine pupil movement. Normally the eyes should follow the direction of head movement. Doll's eyes, pupils move opposite to the direction of head movement and this indicates severe encephalopathy. Examine the suck, place your finger into the baby's mouth and assess the degree of suck. A weak or absent suck may indicate encephalopathy. Also assess tonic neck reflex when moving the head to one side, the ipsi lateral arm and leg will extend and the contralateral arm and leg will flex producing a fencing position. A very pronounced or absent response can indicate encephalopathy. Listen to the heart and lungs and review the baby's observations. Bradycardia, irregular respirations or apnea and excessive secretions may be indicators of encephalopathy. Now, we will assess neuromuscular control, examine the posture of the baby's arms and legs and look for spontaneous movements. Normally, these should be flexed with good tone and normal spontaneous movements. If the baby is excessively flexed and stiff or very floppy with limbs extended in a frog's legs position. This may indicate encephalopathy, hold the baby by both wrists and gently lift upwards into a sitting position, observing the head, neck and shoulders. Normally, the baby should have good tone in the neck and shoulders with mild head lag. If any, if the tone is very stiff or if there's significant head lag, this can indicate encephalopathy. Now hold the baby under both arms in their axilla and get a sense of their central tone. Normally, it should be easy to hold the baby in this posture. If they are sliding through your hands, this can indicate low tone and encephalopathy. Hold the baby in ventral suspension. Normally, the baby should have a relatively straight back with the head in line with the body. If the back significantly curves over your hand with the head and limbs hanging downwards, this can indicate low tone and encephalopathy. Check the morrow reflex, hold your hand below the infant's shoulders and suddenly bring your hand downwards simulating a fall. A normal response will see the baby symmetrically abduct, both arms followed by rapid abduction. If the baby shows prolonged abduction without abduction or no response, this can indicate encephalopathy, check the knee jerk reflexes, very brisk reflexes can indicate encephalopathy. Remember upgoing planters is normal in a newborn baby. If there is a very asymmetric response to your mo and knee reflexes, this can indicate a focal lesion either of the central or peripheral nervous system more than encephalopathy. In a very alert and visually interactive baby with severe central and peripheral floppiness weakness and absent, peripheral and central reflex. This is likely to be due to a neuromuscular disorder and these babies should be discussed with neurology. Now that you have completed your clinical assessment, you can compare your findings to the sarne scoring system, a scoring system to grade the severity of encephalopathy. As we mentioned to meet criteria for cooling, the baby must have reduced alertness as well as at least one of altered reflexes, reduce tone, reduce suck or seizures. In this case, the baby was lethargic and sleeping. They had reduced central tone with reasonable peripheral tone. They had an absent suck and brisk knee jerk reflexes they would therefore have met criteria B in some units. The decision for cooling is made on clinical grounds alone and we would commence it for this baby at this stage. Others you use a period of CFM monitoring to confirm the presence of encephalopathy. We will look at CFA in another video linked at the end of this one, a baby who is being cooled should be restricted to 40 mils per kilogram per day. It is good practice to have a UVC and U A in place. As venipuncture is extremely difficult in a cold baby, analgesia should be given for example, a morphine IV infusion to reduce distress and shivering. They should be killed for a period of 72 hours and then slowly rewarmed. An MRI scan should be done around day 7 to 10 of life to look for any ischemic changes. Healing has some complications that you should be aware of. It can cause hypotension, bradycardia and arrhythmias. It can worsen respiratory distress syndrome and reduce oxygen delivery at the tissues. There is an increased risk of sepsis, electrolyte disturbance and coagulopathy. These patients need to be closely monitored with regular blood testing, blood gasses and BP monitoring. Also remember that it is not just the brain that takes hypoxic damage in hie and acute kidney injury, acute liver injury and adrenal insufficiency are common after severe hie. How can you explain curing to parents? You should explain that it consists of a cooling mat and internal thermometer which reduced the baby's core temperature to help reduce the inflammation in their brain. After short of oxygen at delivery, there is evidence that this can improve the brain's healing and the child's later development advise that it will last at least 72 hours and then the baby will be slowly rewarmed and all the equipment removed. The baby may need to have a breathing tube and central lines in during the period of cooling to closely monitor and support them. Explain that CAM measures the baby's brain activity and helps us to pick up abnormal electrical activity early so that we can treat any seizures that develop. Thanks so much for watching. Please like this video. Comment with any clinical questions or feedback you have and subscribe to the channel and our other social media accounts including Instagram, Twitter, Med all and Ola to stay up to date with future videos. I look forward to seeing you again soon.