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• Therapeutic Hypothermia in Mild Hypoxic Ischemic Encephalopathy
  Shabih Manzar
  Published on: 11 May 2022

• Published on: 11 May 2022

  Therapeutic Hypothermia in Mild Hypoxic Ischemic Encephalopathy

  • Shabih Manzar, Neonatologist Louisiana State University Health Sciences Center Shreveport, LA

  I agree with Yieh et al [1] that there is an overuse of therapeutic hypothermia (TH) in mild HIE resulting in increased resource utilization. The two main reasons we see this practice are the fear of litigation and scare that infant would later have neurological problems. DuPont et al [2] reported abnormal short-term neurologic outcomes in 20% of newborns with perinatal acidemia and mild HIE not treated with TH. However, in the same study they had 14% of infants that did not receive TH despite the neurological examination consistent with moderate and severe HIE.
  Mehta et al [3] have earlier described overutilization of TH in mild HIE, recommending a robust review of the eligibility criteria definitions, especially the 10-min Apgar score. The subjectivity of TH criteria put the practitioner in a decision dilemma. For example, out of five components of Apgar score, only heart rate assessment is objective. A color score of 1 or 2 can change the Apgar from 5 to 6. Similarly, a slight variation in observer examination in obtaining Sarnat score could change it from mild to moderate. Therefore, using a combination of factors in deciding about TH would be a better approach [4].
  One of the most important criterion for TH is presence of perinatal academia. Recently, Blecharczyk et al [5] have shown the benefits of standardized screening pathway for evaluating abnormal cord gases in neonates at risk for HIE. Following a structured pathway resulted in minimizing unnecess...

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  I agree with Yieh et al [1] that there is an overuse of therapeutic hypothermia (TH) in mild HIE resulting in increased resource utilization. The two main reasons we see this practice are the fear of litigation and scare that infant would later have neurological problems. DuPont et al [2] reported abnormal short-term neurologic outcomes in 20% of newborns with perinatal acidemia and mild HIE not treated with TH. However, in the same study they had 14% of infants that did not receive TH despite the neurological examination consistent with moderate and severe HIE.
  Mehta et al [3] have earlier described overutilization of TH in mild HIE, recommending a robust review of the eligibility criteria definitions, especially the 10-min Apgar score. The subjectivity of TH criteria put the practitioner in a decision dilemma. For example, out of five components of Apgar score, only heart rate assessment is objective. A color score of 1 or 2 can change the Apgar from 5 to 6. Similarly, a slight variation in observer examination in obtaining Sarnat score could change it from mild to moderate. Therefore, using a combination of factors in deciding about TH would be a better approach [4].
  One of the most important criterion for TH is presence of perinatal academia. Recently, Blecharczyk et al [5] have shown the benefits of standardized screening pathway for evaluating abnormal cord gases in neonates at risk for HIE. Following a structured pathway resulted in minimizing unnecessary evaluations, admissions to NICU and disruption of neonate–mother bonding.
  In conclusion, the role of TH in mild HIE in reference to the long-term neurodevelopmental outcomes remain unclear. When using TH in mild HIE, healthcare cost and resource utilization should be considered.

  References:

  1. Yieh L, Lee H, Lu T, et al. Neonates with mild hypoxic-ischaemic encephalopathy receiving supportive care versus therapeutic hypothermia in California. Arch Dis Child Fetal Neonatal Ed. 2022;107(3):324-328. doi:10.1136/archdischild-2021-322250

  2. DuPont TL, Chalak LF, Morriss MC, Burchfield PJ, Christie L, Sánchez PJ. Short-term outcomes of newborns with perinatal acidemia who are not eligible for systemic hypothermia therapy. J Pediatr. 2013;162(1):35-41. doi: 10.1016/j.jpeds.2012.06.042

  3. Mehta S, Joshi A, Bajuk B, Badawi N, McIntyre S, Lui K. Eligibility criteria for therapeutic hypothermia: From trials to clinical practice. J Paediatr Child Health. 2017;53(3):295-300. doi:10.1111/jpc.13378

  4. Bonifacio SL, Hutson S. The Term Newborn: Evaluation for Hypoxic-Ischemic Encephalopathy. Clin Perinatol. 2021;48(3):681-695. doi: 10.1016/j.clp.2021.05.014

  5. Blecharczyk E, Lee L, Birnie K, et al. Standardized Evaluation of Cord Gases in Neonates at Risk for Hypoxic Ischemic Encephalopathy. Hosp Pediatr. 2022;12(1):29-37. doi:10.1542/hpeds.2021-006135

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  Conflict of Interest:
  None declared.

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