Early Screening and Identification of Candidates for Neonatal Therapeutic Hypothermia Toolkit

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Therapeutic hypothermia, when implemented within 6 hours of birth, has been shown to significantly improve survival and neurodevelopmental outcomes in neonates with moderate to severe hypoxic ischemic encephalopathy (HIE) 19. Unfortunately, not every baby who might benefit from cooling therapy is identified or referred to a regional cooling center in a timely fashion. Early identification of the risk factors for perinatally-acquired asphyxia and recognition of the signs and symptoms of neonatal encephalopathy are challenging even for experienced neonatologists, let alone primary care providers at community delivery hospitals when significant HIE may occur in only 1-3/1000 live births. Accurate neurologic assessments and timely consultations with a regional cooling center should occur so that appropriate decisions can be made about initiating cooling and potentially transferring care.

Some neonates with only minimal or mild signs of encephalopathy, even with other risk factors, may appropriately be observed at delivery hospitals with good expectations for a favorable outcome. However, initial signs and symptoms of neonatal encephalopathy or seizures may be subtle or subclinical. Many providers at delivery hospitals may not be accustomed to conducting detailed neurologic assessments of encephalopathic newborns. Therefore, the use of reliable screening and assessment tools as well as early consultation with a neonatologist at a regional cooling center familiar with this patient population can greatly facilitate this critical decision- making process. If cooling therapy is determined to be indicated, prompt referrals can expedite safe transport to a tertiary care NICU appropriately equipped to provide the full course of therapeutic hypothermia and its associated specialized care. The sooner a baby with HIE is identified, the sooner the appropriate therapies can be initiated and outcomes optimized.

While each cooling center may have slightly different criteria for initiating cooling therapy, the overall goal of this toolkit is to improve early screening at all delivery hospitals so that thoughtful evaluations occur for each baby with significant risk factors for HIE. It is therefore important to recognize that these are screening criteria only, meant to improve early identification of at-risk babies who might warrant closer assessment. They are intentionally designed with more inclusive criteria and are NOT by themselves qualifying criteria for cooling therapy. It is therefore essential that these guidelines be coupled with ongoing staff education and training. We hope the strategies outlined in this toolkit will help ensure that no baby who might qualify for cooling therapy would miss the opportunity to benefit from it.

We would like to acknowledge the contribution of the members of the Bay Area Cooling Summit, a collaborative consortium of regional cooling centers with the common goal to improve outcomes of neonates at risk for brain injury from HIE, in developing this toolkit.